Technology (5)

EDITOR’S NOTE: This is the fifth article in a series addressing the definitions and differences between the Medical and Surgical Root Operations of ICD-10-PCS.

As usual, let’s review what we have covered so far. In the Medical and Surgical section (first character 0) there are 31 root operations using standardized terminology with no procedure names, no diagnostic information and no eponyms.

So far we have touched on 18 of them, so we are more than halfway there. We have discovered that a fraction reduction is assigned the root operation “reposition,” and that there is no appendectomy designation in ICD-10-PCS. Coders will need to know that the cutting out or off, without replacement, of all of a body part is a “resection.” Since an appendectomy typically involves the total removal of the appendix, “resection” is the correct root operation. This is the type of translation the coder must make to ensure accurate code assignment.

Coders will find this topic covered in the ICD-10-PCS book, Appendix A and B. The PCS appendices are rich with helpful information meant to assist coders in the translation of medicine to PCS. That is for future discussion, as today we are focusing on the procedures that alter the diameter or route of a tubular body part. As in the ICD-10-PCS book, we will review the definition, explanation, and some examples of each. We also will introduce the applicable coding guidelines. The character listed after each root operation represents the third character in the PCS code.

There are six root operations that have been grouped into procedures that always involve devices. They include:


Insertion (H)

Definition: Implanting a non-biological device that monitors, assists, performs or prevents a physiological function, but does not physically take the place of a body part.
Explanation: None
Examples: Insertion of radioactive implant, insertion of central venous catheter.
Coding Guideline: Reposition for fracture treatment (B3.15)
Reduction of a displaced fracture is coded to the root operation “reposition” and the application of a cast or splint in conjunction with the reposition procedure is not coded separately. Treatment of a non-displaced fracture is coded to the procedure performed.
Example: Putting a pin in a non-displaced fracture is coded to the root operation “insertion.” Casting of a non-displaced fracture is coded to the root operation “immobilization” in the Placement section.
Replacement (R)
Definition: Implanting or applying a biological or synthetic material that physically takes the place and/or function of all or a portion of a body part.
Explanation: The body part may be taken out, replaced, physically eradicated or rendered nonfunctional during the replacement procedure. A removal procedure is coded for taking out a device used in a previous replacement procedure.
Examples: Total hip replacement, bone graft, free skin graft, mastectomy with free TRAM flap reconstruction.
Coding Guideline: General guidelines (B3.1b)
Components of a procedure specified in the root operation definition and explanation are not coded separately. Procedural steps necessary to reach the operative site and close the operative site also are not coded separately.
Example: Resection of a joint as part of a joint replacement procedure is included in the root operation definition of “replacement” and is not coded separately. Laparotomy performed to reach the site of an open liver biopsy also is not coded separately.



Supplement (U)
Definition: Implanting or applying a biologic or synthetic material that physically reinforces and/or augments the function of a portion of a body part.
Explanation: The biological material is nonliving, or is living and from the same individual. The body part may have been replaced previously, and the supplement procedure is performed to physically reinforce and/or augment the function of the replaced body part.
Examples: Herniorrhaphy using mesh, free nerve graft, mitral valve ring annuloplasty, implantation of a new acetabular liner in a previous hip replacement.
Coding Guidelines: There are no guidelines addressing the supplement procedure.
Change (2)
Definition: Removing a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane.
Explanation: All change procedures are coded using the approach “external.”
Examples: Urinary catheter change, gastrostomy tube change, replacement of chest tube.
Coding Guideline: General guidelines (B6.1c)
Procedures performed on a device only and not on a body part are specified in the root operations change, irrigation, removal and revision, and are coded to the procedure performed.
Example: Irrigation of percutaneous nephrostomy tube is coded to the root operation “irrigation” of indwelling device in the Administration section.
Removal (P)
Definition: Removing a device from a body part.
Explanation: If a device is taken out and a similar device is put in without cutting or puncturing the skin or mucous membrane, the procedure is coded to the root operation “change.” Otherwise, the procedure for taking out a device is coded to the root operation “removal.”
Examples: Drainage tube removal, cardiac pacemaker removal.
Coding Guidelines: There are no guidelines addressing removal.
Revision (W)
Definition: Correcting, to the extent possible, a malfunctioning or displaced device.
Explanation: Revision can encompass correcting a malfunctioning device by taking out and/or putting in part of the device.
Examples: Adjustment of pacemaker lead, adjustment of hip prosthesis, reposition of Swan-Ganz catheter.
Coding Guidelines: There are no guidelines addressing revision.


Our last groups of ICD-10-PCS Medical and Surgical Root Operations to explore are procedures involving cutting or separation only, procedures involving other repairs and procedures with other objectives.

About the Author

Becky DeGrosky, RHIT, is the Product Manager for TruCode. She brings over 35 years experience in health information management.  She worked for 11 years in HIM software development for QuadraMed and MedAssets, including product management, content maintenance, implementation and training, and client support.  She is an active member of the Pennsylvania Health Information Management Association, where she has served on multiple committees including Chairman of the Education Committee and the Coding Roundtable.

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“To use GEMs, or not to use GEMs?” That is a question posed by many ICD-10-minded people these days. To address this issue, let’s take a look at what GEMs are not. Experts are recommending that GEMs not be used as a primary coding resource or used to code current claims, and the experts are correct. GEMs should not replace your ICD-9-CM code books and encoders. The final ICD-10-CM code set has yet to be determined. Since the codes are not final and the CMS database has not been perfected, using GEMs as a coding reference is premature.

But here is what GEMs can do for you. Simply stated, top experts agree that GEMs are among the best ICD-10 educational tools available today. Enhanced GEMs software solutions provide cost-effective ICD-10 training that creates immediate staff and provider awareness.

Engaging providers in sweeping, mission-critical change is always a challenge. For ICD-10, providers and practice administrators know they need to get started on the transition, but many have no idea how to begin the conversation. An affordable (cheaper than the cost of code books), automated GEMs tool is the perfect way to initiate the process. Putting this easy-to-use software in the hands of everyone – from the billing clerk who barely deals with diagnoses to the most experienced provider and coder – is a great way to kick-start the ICD-10-CM transition.

Why is this? A GEMs translator can be used to illustrate the structural differences between digital ICD-9 codes and alphanumeric ICD-10 codes for your most frequently captured diagnoses. GEMs can demonstrate the dramatic difference in specificity between the code sets and the need to capture laterality, degree of severity or healing and encounter type under ICD-10. GEMs can be used to create side-by-side contrasts illustrating ICD-10 documentation needs compared to those required for ICD-9.

Offering this immediate visual representation of the increased detail required for documentation, charting and coding is an excellent way to engage everyone affected.

Please note that we are not referring to the free online versions that provide limited “one-code-lookup” functionality. Rather, we are suggesting a tool that provides multiple bi-directional searches by code or code description, and one that has a print function to create quick reference guides and a storage capability to warehouse the most frequently used diagnoses.

Saving precious time that most practices can’t currently spare may be the most valuable GEMs benefit. The crystal ball says that within the next six months, providers at practices finally beginning the ICD-10 journey will be asking their staff to “translate” most frequently used ICD-9 codes so those practices can become familiar with the new coding and documentation conventions. Imagine having to use code books to convert two ICD-9-CM patella fracture codes to 480 ICD-10-CM codes. This could take hours. Using a suitable GEMs tool, it takes seconds.



Everywhere a diagnosis code touches your practice, there exists paper/technology and human impact. For example, superbill and EMR chart note templates require ICD-10 conversion. All order entry (lab, X-ray, PT, OT, DME) requires ICD-10 translation. Pre-authorization of insurance is something that needs to be addressed, as are referrals to outside providers. Do not minimize the human element in these impact areas. Converting to ICD-10 using GEMs fosters familiarity for every staff member, no matter how peripheral. Plus, early awareness breeds comfort. Ultimately, the goal is to implement cost-effective training. Beginning that process now gives any practice a leg up when coding training begins.

Using GEMs to perform chart audits that gauge your current documentation’s ability to support specific ICD-10 codes is easy. Again, you could use ICD-9-CM and draft ICD-10 code books to accomplish these conversions. But why would you when there are fully functional GEMs alternatives on the market that cost less than a diagnosis code book set – tools that could save hours of valuable time and ultimately reduce the stress and strain on your staff?

Using a print-capable GEMs tool to create quick reference documentation and coding guidelines is a snap. Again, imagine how long it would take to create a documentation comparison table manually using code books. Using a printable GEMs resource allows you to print custom flash cards for codes, descriptions and new documentation requirements instantly rather than engaging in the time-consuming task of entering dozens of codes and code descriptions by hand.

Again, according to the experts, GEMs may not be a reference from which you currently can code claims. However, it is the most cost-effective resource available to educate, train and create awareness among staff and providers regarding ICD-10-CM’s dramatic projected impact.

Your job is about to get a lot harder. But taking advantage of the right GEMs tool definitely can help.

About the Author

Denny Flint is president of Complete Practice Resources. Denny formerly served as the CEO of a large, multi-specialty physician group, a full service MSO and was a certified professional coder through AAPC. He has authored or co-authored numerous “common sense” practice management books and implementation manuals. Educated at the United States Air Force Academy, he had a distinguished career as an Air Force pilot flying numerous secret and sensitive missions.

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As if hospital administrators didn’t have enough to worry about these days, they’re now staring down the significant risk of productivity and revenue losses that could come as a result of ICD-10 implementation – unless they start preparing now.

With denied claims expected to more than double, going from 3 percent to 6-10 percent, a 250-bed hospital could take a financial hit of as much as $850,000 in 2014 due to lost productivity, denied claims and undercoding (see Figure 1) resulting from the use of more complex ICD-10 codes. Add in the intensifying coder shortage and many healthcare organizations are at a loss to identify where to begin solving this impending crisis.

The compliance deadlines for 5010 and ICD-10 are approaching rapidly – Jan. 1, 2012 for the adoption of the Version 5010 legislated processing requirements and Oct. 1, 2013 for the ICD-10 code set changes. While HIPAA industry participants legally are required to switch to ICD-10, the mandate offers an opportunity to think about ICD-10 as more than a coding initiative and use it as a catalyst to implement process improvements that can impact profitability.

Organizations may be inclined to look to do the bare minimum in the face of government mandates to ensure compliance. On its own, ICD-10 will not change how care is documented nor how it is delivered. As organizations prepare for ICD-10, they should look beyond the mandate and consider the opportunities and strategic value created by the legislation. Using this time to develop a comprehensive assessment and strategic plan will help identify risks as well as opportunities for improvement.

An assessment is a critical component of plan development to ensure that ICD-10 delivers value and not just a change in how medical encounters are coded. By documenting current conditions and focusing on desired benefits from system upgrades and process changes, healthcare organizations can choose to promote better disease management, better reporting and analytics and streamlined claim processing procedures.

Strategic Considerations for Assessments

When developing a strategic plan, it’s important to get key stakeholders involved in order to offer a broader perspective on the potential scope and impact of the plan. This is because changes can have financial impact and affect operations and systems. With assistance from executive leadership, one of the first things to consider in moving to ICD-10 is whether your approach will be tactical (simply complying with the government mandate to use the new code set) or transformational (helping to improve processes and realize value beyond compliance).

Transformational process improvements involve modification of all processes and system touch points. The project also may involve interdependencies with other initiatives such as implementation of EHRs, consideration of how accountable care organization strategies are impacted and developing or changing system structures.

An assessment delivers value in plan development because it identifies strengths and weaknesses, enabling organizations to create a roadmap for the future. It also allows organizations to develop a multi-year plan for compliance and improvements.

Rather than thinking of ICD-10 adoption as a nothing-to-gain project, organizations should challenge themselves to find the return on investment in operations to fund the adoption plan and other initiatives. For executive leadership, it is critical to understand the magnitude of the change beyond a code set upgrade.

For example, CFOs need to be aware if there are shifts in payments and responsible parties in healthcare. They need to understand the impact as well as the effects of quality-based payment plans. They need to understand the risks involved in the ICD-10 adoption project and agree to support the opportunities that have upside potential while also demanding reporting on the potential financial impact to cash flows, pay-for-performance plans, bundled payments, payer contract terms and more.


CIOs need to evaluate and understand the complexity of technology issues in order to provide insight into changing systems, interoperability, testing timeframes and other system considerations such as natural language processing, documentation improvement programs and computer-assisted coding applications. Because changes in these systems potentially can affect both clinical and administrative practices, the CEO needs to understand data in order to drive greater analytics to support the strategic plan of the organization. He or she also must take advantage, to the greatest extent possible, of all the opportunities available with the new code sets.

Key steps to be taken when preparing for an assessment include:

*Evaluate current financial conditions and limitations to prioritize investments and inform decision-making.

*Garner input from the payer community to gather insight into rates and reimbursements in order to understand how commercial payers are changing their systems. This is critical because it can have a significant impact on an organization’s financial health and profitability.

*Think about the long-term impact of ICD-10 on coding staff and productivity. Will implementing sooner rather than later and having a strategic plan of action help avoid a dip in productivity during the transition or after Oct. 1, 2013?

*Take into account the impact of computer-assisted coding and how it will affect staff. Will coders need additional training to develop the skills to become auditors of automated processes?

*Make decisions now regarding new systems so your organization will have sufficient time for budgeting, procurement, implementation and testing. This also ensures that when a system change is necessary, your organization will not get closed out from working with a vendor of choice due to capacity constraints.

The Value of Outside Insight

Completing assessment work can be done with internal or external resources. The value of outsourcing the assessment is that you might uncover details you otherwise would miss. An outsourcing partner will have amassed experience from working with multiple clients and can share insight on industry best practices.

An outsourcing partner also will provide an independent view of the organization and ask key questions that internal representatives may overlook (or be too close to the information to identify as areas of improvement). As with any type of widespread organizational change, good change management processes are essential for success. Outsourcing can provide expertise in change and transition management to support adoption of new processes and systems.

While some organizations may have sufficient resources to conduct a strategic assessment on their own, this still shifts their focus away from core business priorities. Working with an outsourcing provider frees internal resources for other work.

Establishing a baseline assessment with a strategic view is a critical starting point in implementing a successful ICD-10 adoption plan. A strategic assessment will help healthcare organizations in developing a strategy, evaluating risks and prioritizing tasks before the impending deadline.


By identifying change opportunities early in the process (even now is almost too late) and thinking strategically with ICD-10, organizations can go beyond the legislated coding mandate to implement the new code sets and support strategic initiatives that will have an impact on the bottom line.

These initiatives should include validating coding and documentation processes for maximum compliance accuracy, revamping systems to take advantage of new technology, and monitoring system changes for compliance made by business associates such as payers, vendors and billing partners.

About the Author

Veronica Hoy, MBA, is vice president of SOURCECORP HealthSERVE Consulting, Inc. Veronica has been an operating executive for 10 years, focusing on providing strategic leadership and direction to healthcare professionals and organizations. She has more than 20 years of healthcare experience in business process outsourcing, accounts receivable management, coding, billing, release of information, consulting and systems implementation.

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ED. NOTE: This is Part 2 in a three-part series of articles on the impact of technology and ICD-10.

In Part 1 of this series I discussed the importance of performing an ICD-10 risk assessment at your facility sooner rather than later. What I have noticed is that some have begun, but many others have their heads buried in the sand. For those of you who have kept current and are trying to wrap your arms around this big undertaking, I’d like to share some implementation-related best practices I have learned from my fellow colleagues: in particular I will be focusing on the strategy and workflow processes you may want to consider as you implement ICD-10 at your facility.

I had the opportunity to attend the AHIMA ICD-10 Summit in April, and one remark that stood out to me indicated that almost every system in your facility will be affected by ICD-10, with the exception of housekeeping. “Really?” I thought to myself. Yes, really – one director of patient financial services spoke about more than 80 systems being affected at his facility. This same director’s strategy when it came to ICD-10 was to take the opportunity to improve the overall business practices of his organization, looking at ICD-10 as a “benefit” versus a “have to.” The organization developed a strategy in regard to ICD-10 that allowed it to better measure outcomes, enhance clinical care to promote wellness over time, begin accountable care organization (ACO) negotiation with contracting, consider the opportunity to earn stimulus funding by becoming early adopter of ICD-10, and provide physician education.

A big part of an effective strategy is organizing the effort around ICD-10 and developing project goals. Particularly, one of these common goals should be to establish a governing body. The governing body should take a “top down” approach, as leadership typically should lead the charge for change within a facility. This governing team will create a timeline and define responsibilities and priorities.

Some of the project goals also should include facilitating organizational awareness, support education and training, coordination of resources, understanding of reimbursement impact and the linkage of technology requirements with informational needs. The governing team will include moving parts, and not just leadership.

Whereas there will be some who serve as part of project management and focus on establishing project goals, an advisory team of key stakeholders will focus on outcomes, budget impact and continuous evaluation of those goals.

Furthermore, a steering committee will concentrate on impacted systems and departments, such as information technology, clinical and financial members.

There are many areas in your organization to think about from a technology perspective. Will all systems be go come Oct. 1, 2013? As you think about your strategy and workflow with regard to ICD-10, consider the following:

Information Technology - Understand how you currently do business under ICD-9.  There needs to be an assessment of all systems that utilize ICD-9 codes.

Check all systems with the exception of housekeeping.

-         Perform a system inventory of ICD-9 data storage.

-         Be 5010-ready.

-         Understand system transitions and conversions of historical data.

Reporting – Understand the reporting workflow impact of ICD-9 to ICD-10 and vice versa.

-         Identify all current reporting workflow processes that utilize ICD-9 data.

-         Assess which vendors are available to facilitate understanding of the comparisons from I-9 to I-10.

-         Identify what tools are available on the market to facilitate understanding of the transition process and assure that GEMS mapping available through CMS is part of the workflow tool assessment.

    • Perform a vendor readiness survey.

Finance - Understand what the reimbursement impact on your facility will be and assess payer readiness.

-         Assess payer contracts – now is the time to negotiate.

    • Negotiations should include preparing future contract language to include references to ICD-10.
    • Create a payer readiness survey.

-         Perform a reimbursement impact analysis (using reimbursement maps provided by CMS).

    • Recommend starting with top 10 DRGs at your facility.

Documentation – Understand your risk related to documentation. It is probable that documentation is a key area of risk due to the specificity involved in coding with ICD-10.

-         Recommend engaging a third-party vendor to review documentation.

    • Consider the ratio of records slated for review to hospital bed size:  review 100-200 records per 100-300 beds.
    • Review third-party documentation recommendations and identify gaps in current documentation processes; revise templates as warranted and educate physicians on documentation requirements.

Education – Identify training needs for all personnel. Training will be differentiated based on staff roles.

-         Start with ICD-10 educational awareness programs.

-         Identify methods, timing and depth of training by type of personnel.

    • Account for ongoing education and new staff training.

Team ICD-10 – Identify members who will drive all of the moving parts to implementation. For some, this is the steering committee.

-         This team needs to ensure that all areas that could be affected by ICD-10 are addressed.

-         Members must be involved in training and education, ensuring that every aspect of the transition is communicated clearly throughout the organization.


It’s overwhelming to say the least, but the implementation process needs to be addressed. As you look at your current workflow processes, you may want to modify your current workflow or revamp it completely. It truly depends on how well your current processes work under ICD-9. Just remember that implementing ICD-10 is a work in progress and you can and will need to be flexible.

Ultimately, change can be good, as it often provides an opportunity to improve.

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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