October 25, 2013

FY2014 Guidelines Include Significant Change

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The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS) continue to update the official guidelines related to ICD-10-CM/PCS coding.  This article summarizes the ICD-10-PCS guidelines only, including one significant change from the FY 2013 guidelines.

A quick review of the introductory section emphasizes that the 2014 guidelines are a set of rules developed to accompany and complement the official conventions and instructions provided within the ICD-10-PCS itself.  As a reminder, the instructions and conventions within ICD-10 take precedence over these guidelines.  Although based on the coding and sequencing instructions in the Tables, Index and Definitions of ICD-10-PCS, the guidelines provide additional instruction.  Also important to remember is that the Healthcare Insurance Portability and Accountability Act (HIPAA) requires that providers adhere to these guidelines when assigning ICD-10-PCS procedure codes, which  HIPAA mandated for use in the hospital inpatient setting.

 

In addition to guidelines, the introduction also provides good advice.  As stated, a joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.  The purpose of these guidelines is to help both parties identify the diagnoses and procedures to report.

The guidelines are organized into the following sections:

  • Section A – Conventions
  • Section B – Medical and Surgical
  • Section C – Obstetrics
  • Section D – Selection of Principal Procedure

The most significant change in the FY 2014 guidelines is the addition of Section D. This is a welcome addition since the ICD-9-CM Official Guidelines for Coding and Reporting did not include the appropriate selection of the principal procedure.

SECTION A – CONVENTIONS

No changes have been made to this section for 2014.  In items A1–A9, the guidelines include discussion of the composition of the PCS codes, valid values, axis of classification, the use of the index vs. tables, and building a valid code within a table.  Two important items to remember in this section are: 

  • A10 – the word “and” in the code description means “and/or”
  • A11 –it is the responsibility of the coder to determine what the documentation in the medical record equates to in the PCS definitions.

SECTION B – MEDICAL AND SURGICAL GUIDELINES

This section is broken down by the different characters that will make up the code in the Medical and Surgical section:

  • B2 – Body System
  • B3 – Root Operation
  • B4 – Body Part
  • B5 – Approach
  • B6 – Device

The only change in this section of the guidelines is identified in Section B3 for Root Operation.  In the 2013 guidelines, B3.4 discussed biopsy followed by a more definitive treatment.  This guideline remains but has been expanded to B3.4a for “biopsy procedures” followed by B3.4b for “biopsy followed by more definitive treatment.” Guideline B3.4a states:  “Biopsy procedures are coded using the root operations Excision, Extraction, or Drainage and the qualifier Diagnostic.  The qualifier Diagnostic is used only for biopsies.”

SECTION C – OBSTETRICS SECTION GUIDELINES

This section contains two guidelines for products of conception and procedures following delivery or abortion.  There were no changes made to the guidelines in this section.

SECTION D – SELECTION OF PRINCIPAL PROCEDURE

This section of the guidelines was added by CMS and NCHS for 2014.  It provides the steps to follow for selection of the principal procedure when more than one procedure is performed during the patient encounter.   

  1. Procedure performed for definitive treatment of bothprincipal diagnosis and secondary diagnosis.
    1. Sequence procedure performed for definitive treatment most related to the principal diagnosis as principal procedure.
  2. Procedure performed for definitive treatment and diagnostic procedures performed for both principal diagnosis and secondary diagnosis.
    1. Sequence procedure performed for definitive treatment most related to the principal diagnosis as principal procedure.
  3. A diagnostic procedure was performed for the principal diagnosis and a procedure is performed for the definitive treatment of a secondary diagnosis.
    1. Sequence diagnostic procedure as principal procedure, since the procedure most related to the principal diagnosis takes precedence.
  4. No procedures performed that are related to the principal diagnosis; procedures performed for definitive treatment and diagnostic procedure were performed for secondary diagnosis.
    1. Sequence procedure performed for definitive treatment of secondary diagnosis as principal procedure, since there are not procedures (definitive or non-definitive treatment) related to principal diagnosis.

The 2014 ICD-10-PCS Official Guidelines for Coding and Reporting can be downloaded from the CMS website using this link:  http://www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-PCS.html

About the Author

Susan Howe is a senior healthcare consultant, clinical consulting services, with Panacea Healthcare Solutions, Inc.

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