1. When reporting biopsies with more definitive procedures, don’t forget to code the biopsy in addition to the main procedure. In some cases, the physician will perform a more definitive procedure (e.g., destruction, excision, or resection) after he or she performs a biopsy (i.e., diagnostic excision, extraction, or drainage). When the biopsy and definitive procedure occur at the same operative site, report both procedures.
For example, biopsy of a skin lesion denotes melanoma on frozen section. The surgeon performs extensive excision of tissue from the area. Coders should report both the biopsy and excision of tissue.
2. Understand the concept of external approach. Report an external approach for procedures performed within an orifice on structures that are visible without the aid of any instrumentation. For example, report an external approach for release of a tongue tie.
Open procedures require the physician to cut through skin, subcutaneous tissue, or other tissue to expose the site of the procedure.
3. Don’t forget about Appendix D (body part key). For example, the PCS table for a tendon repair doesn’t include an option for the Achilles tendon. However, when referencing the body part key, the coder is directed to the lower leg tendon.
4. Use other appendices included in the ICD-10-PCS Manual. For example, Appendix F (device key and aggregation table) provides information about certain devices and their corresponding PCS descriptions.
Appendix G provides a PCS description and corresponding device terms.
5. Understand the main objective of the procedure to determine the root operation. For example, a patient with a stenotic urethra undergoes placement of a stent.
The main objective of the procedure is to dilate the urethra and not simply to insert a stent. Dilation is the proper root operation.
Two points to remember:
- The root operation is based on the procedure actually performed, which may or may not have been the intended procedure.
- If the desired result is not attained after completion of the procedure (i.e. the artery does not remain expanded after the dilation procedure), the root operation is still determined by the procedure actually performed.
Be sure to keep the 2016 ICD-10-PCS guidelines handy to ensure compliance and refresh your memory until these guidelines become more familiar.
