Updated on: November 28, 2016

Five Tips to Ensure Compliance with ICD-10-PCS: Part One

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Original story posted on: November 23, 2015

In a previous article, we reviewed several important ICD-10-CM guideline changes. This month, we’ll present the first piece in a two-part series that focuses on ICD-10-PCS: the system that everyone feared would slow productivity and cause the majority of problems related to documentation insufficiencies. 

At this point, the jury is still out in terms of whether these fears have proved legitimate. The industry won’t know for sure until several weeks have elapsed whether PCS will require additional documentation improvement efforts and/or PCS-focused refresher training for coders.

In the meantime, coders should take the time to review the 2016 ICD-10-PCS guidelines and remind themselves of these five coding tips to ensure PCS compliance (Note: We’ll cover five additional coding tips next month):

1. Distinguish between excision and resection. The root operation “excision” refers to cutting out or off, without replacement, a portion of a body part. The root operation “resection” refers to cutting out or off, without replacement, all of a body part. It’s easy to confuse the two because they are so similar. Additionally, in ICD-9, excision and resection were synonymous. 

In ICD-10, coders must determine whether all (or a portion of) a body part is removed. To do so, the coder must interpret physician documentation accurately. For example, although the physician may document that he or she resected the sigmoid colon, a review of the operative report may indicate that only a portion of the sigmoid was removed. This translates to excision rather than resection.  

Secondly, coders must reference the PCS table to determine the accurate body part value. For example, in the hepatobiliary and pancreas body systems, body part values for liver include right liver lobe and left liver lobe. Therefore, open removal of the entire right liver lobe would be considered a resection (ICD-10-PCS code 0FT10ZZ) because the entire body part (as designated by the PCS table) has been completely removed. 

2. During a fine needle biopsy, note whether tissue or fluid is removed. If a physician removes tissue, the proper root operation is “excision.” If he or she removes fluid, report the root operation “drainage.” For example, say a physician notes a retroperitoneal mass on CT scan for which a fine needle aspiration is performed with removal of fluid from the area. Coders would report ICD-10-PCS code 0W9H3ZX. However, if the fine needle biopsy removes tissue rather than fluid, report ICD-10-PCS code 0WBH3ZX. 

3. When reporting occlusion versus restriction, identify the goal of the procedure. Is the objective to completely close off an orifice or lumen of a tubular body part? Or is it simply to partially close the orifice or lumen? For complete closure, report the root operation “occlusion.” For partial closure, report the root operation “restriction.”   

Consider this example: For tumor embolizations, the goal is to completely cut off the blood flow to the tumor. As such, the root operation is occlusion. However, if a physician performs a gastroesophageal fundoplication with the objective to strengthen the lower esophageal sphincter by wrapping part of the stomach around the sphincter to restrict flow, this is restriction.

The alphabetic index may provide direction in distinguishing the two objectives. For instance, when referencing ligation, the coder is referred to occlusion. However, if the intent of the procedure is not clear, and no index/guideline exists to provide guidance, the coder may need to query the physician or consult a physician advisor.

4. Know how to report lysis procedures using the root operation “release.” When reporting a release, note that the body part value coded is the body part being freed, not the tissue that’s manipulated or cut to free the body part. Some of the restraining tissue may be removed; however, none of the body part is taken in or out. For example, during a carpal tunnel release, the transverse carpal ligament is cut in order to release the median nerve. The median nerve is released; thus that is the body part coded. 

5. Know when to code multiple procedures. ICD-10-PCS Guideline B3.2 specifies that coders should report multiple procedures during the same operative episode when: 

  • The physician performs the same root operation on different body parts as defined by distinct values of the body part character  (e.g., resection of greater and lesser omentum are coded separately).
  • The physician repeats the same root operation in multiple body parts, each of which is separate and distinct classified to a single PCS body part value (e.g., excision of plantar metatarsal vein and plantar venous arch are both included in the foot vein body part value, and multiple procedures are coded).
  • The physician performs multiple root operations with distinct objectives on the same body part (e.g., restriction of sigmoid lesion and bypass of sigmoid colon are coded separately).
  • The physician performs the root operation using one approach but must convert to another approach (e.g., laparoscopic cholecystectomy converted to an open cholecystectomy is coded as percutaneous endoscopic inspection and open resection).   

Also note that inherent components of a procedure specified in the root operation are not coded separately, such as procedural steps necessary to reach the operative site and close it.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Cathie Wilde, RHIA, CCS

Cathie Wilde, RHIA, CCS, is the director of coding services for MRA. Ms. Wilde has been active in the healthcare industry for more than 30 years. Her previous positions have included assistant director of HIM, DRG coordinator at the Massachusetts Hospital Association, and DRG validator at Blue Cross Blue Shield. She has extensive experience in ICD-9-CM and CPT coding, auditing, data analysis, development and testing of coding products, specialized reporting, and in-service training. As director she is responsible for overseeing the coding division, providing the strategic direction of MRA as a local industry leader of quality coding, auditing, and denial management services. Ms. Wilde is an American Health Information Management Association (AHIMA)-approved ICD-10-CM/PCS trainer.

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