May 6, 2013

One Hundred Tips for ICD-10-PCS Coding: Tips 41-50

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ICD-10-PCS represents a major departure from ICD-9-CM procedure coding, and as such, many coding specialists find ICD-10-PCS much more challenging to learn than ICD-10-CM (which still shares many similarities with ICD-9-CM). In order to ease the transition from one code set to the other, we are providing tips for coding under this system.

 

To download the 2013 ICD-10-PCS root operation tables and resources, go online to http://www.cms.gov/Medicare/Coding/ICD10/2013-ICD-10-PCS-GEMs.html.

The following tips are based on documentation guidelines presented at the 2013 ICD-10-CM/PCS Summit by Melissa Myrick of BayCare Health System and Karen Youmans of YES HIM Consulting, Inc.

 

Tip No. 41

Train physicians to document the absence or presence of vessel bifurcation when dictating coronary artery angioplasty reports (documenting, for example, percutaneous transluminal coronary angioplasty/PTCA), because this information is needed for accurate coding of the qualifier in root operation table 027.

Section

0

Medical and surgical

Body System

2

Heart and great vessels

Operation

7

Dilation: Expanding an orifice or the lumen of a tubular body part

 

Body Part

Approach

Device

Qualifier

 

Coronary Artery, One Site

Coronary Artery, Two Sites

Coronary Artery, Three Sites

Coronary Artery, Four or More

Sites

 

 

 

Open

Percutaneous

Percutaneous

Endoscopic

 

 

 

 

Intraluminal Device, Drug-eluting

Intraluminal Device

Intraluminal Device, Radioactive

No Device

 

 

Bifurcation

No Qualifier

 

 

 

 

Aortic Valve

Mitral Valve

Pulmonary Valve

Tricuspid Valve

Ventricle, Right

Pulmonary Trunk

Pulmonary Artery, Right

Pulmonary Vein, Right

Pulmonary Vein, Left

Superior Vena Cava

Thoracic Aorta

 

 

 

Open

Percutaneous

Percutaneous

Endoscopic

 

 

 

Intraluminal Device, Drug-eluting Intraluminal Device

No Device

 

 

 

No Qualifier

 

 

Pulmonary Artery, Left

 

Open

Percutaneous Percutaneous

Endoscopic

 

Intraluminal Device, Drug-eluting Intraluminal Device

No Device

 

Ductus Arteriosus

No Qualifier

 

 


 

Tip No. 42

Train physicians to document the type of materials used to replace the hip joint, because this information is needed for accurate coding of the device in root operation table 0SR.

(The following is an excerpt only, not the complete 0SR table):

Section

0

Medical and surgical

Body System

S

Lower joints

Operation

R

Replacement: Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part

 

Body Part

Approach

Device

Qualifier

 

Hip Joint, Right

Hip Joint, Left

 

 

 

Open

 

 

 

 

Synthetic Substitute, Metal

Synthetic Substitute, Metal on Polyethylene

Synthetic Substitute, Ceramic

Synthetic Substitute, Ceramic on Polyethylene

Synthetic Substitute

 

 

No Qualifier

 

 

 

 


 

Tip No. 43

“Lysis of abdominal adhesions” is not codeable in ICD-10-PCS. To ensure accurate coding of the body part in root operation table 0DN, train physicians to document the specific location of abdominal adhesiolysis.

 

 

 

 

Section

0

Medical and surgical

Body System

D

Gastrointestinal system

Operation

N

Release: Freeing a body part from an abnormal physical constraint by cutting or by the use of force

 

Body Part

Approach

Device

Qualifier

 

1 Esophagus, Upper

2 Esophagus, Middle

3 Esophagus, Lower

Esophagogastric Junction

5 Esophagus

6 Stomach

7 Stomach,Pylorus

8 Small Intestine

9 Duodenum

A Jejunum

B Ileum

C Ileocecal Valve

E Large Intestine

F Large Intestine, Right

G Large Intestine, Left

H Cecum

J Appendix

K Ascending Colon

L Transverse Colon

M Descending Colon

N Sigmoid Colon

Rectum

 

 

 

 

 

 

 

 

 

 

 

 

Open

Percutaneous

Percutaneous Endoscopic

Via Natural or Artificial Opening

Via Natural or Artificial Opening Endoscopic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No Device

 

 

 

 

 

 

 

 

 

 

 

No Qualifier

 

 

 

Anus

 

Open

Percutaneous

Percutaneous Endoscopic

Via Natural or Artificial Opening

Via Natural or Artificial Opening Endoscopic External

 

 

 

 

No Device

 

 

 

No Qualifier

 

Anal Sphincter

Greater Omentum

Lesser Omentum

Mesentery

Peritoneum

 

 

Open

Percutaneous

Percutaneous Endoscopic

 

 

No Device

 

No Qualifier

 

 

 

 

 

 

 


 

Tip No. 44

Train physicians to document the type of contrast used, because this information is needed for accurate coding of some of the root operation tables (such as B20).

Section

B

Imaging

Body System

2

Heart

Operation

0

Plain radiography: Planar display of an image developed from the capture of external ionizing radiation on photographic or photoconductive plate

 

Body Part

Contrast

Qualifier

Qualifier

 

Coronary Artery, Single

Coronary Arteries, Multiple

Coronary Artery Bypass Graft, Single

Coronary Artery Bypass Grafts, Multiple

Heart, Right

Heart, Left

Heart, Right and Left

Internal Mammary Bypass Graft, Right

Internal Mammary Bypass Graft, Left

Bypass Graft, Other

 

 

 

High Osmolar

1 Low Osmolar

Y Other Contrast

 

 

 

 

None

 

 

None

 

 

 

Tip No. 45

Train physicians to document in the operative report the specific tibial artery (anterior and/or posterior) that is operated on, because this information is needed for accurate coding of some of the root operation tables (such as 045).

According to the ICD-10-PCS Body Part Key, the anterior tibial artery includes the anterior lateral malleolar artery, anterior medial malleolar artery, anterior tibial recurrent artery, dorsalis pedis artery, and posterior tibial recurrent artery.

 


 

Tip No. 46

 

Train physicians to document in the operative report the anatomical site where the following infusion devices end: peripherally inserted central catheter (PICC) lines and central venous catheters. This information is needed for accurate selection of the body part in root operation tables (such as 02H).

For example, if a central venous catheter is placed percutaneously and ends in the superior vena cava, the ICD-10-PCS code assignment will be 02HV33Z.

Section

0

Medical and surgical

Body System

2

Heart and great vessels

Operation

H

Insertion: Putting in a non-biological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part

 

Body Part

Approach

Device

Qualifier

 

Coronary Vein

Atrium, Right

Atrium, Left

Ventricle, Right

Ventricle, Left

 

 

 

 

Open

Percutaneous

Percutaneous Endoscopic

 

 

 

 

Monitoring Device, Pressure Sensor

Monitoring Device

Infusion Device

Intraluminal Device

Cardiac Lead, Pacemaker

Cardiac Lead, Defibrillator

Cardiac Lead

 

 

No Qualifier

 

 

 

Heart

 

Open

Percutaneous

Percutaneous Endoscopic

 

 

Implantable Heart Assist System

 

 

No Qualifier

 

Heart

 

Open

Percutaneous

Percutaneous Endoscopic

 

 

External Heart Assist System

 

Biventricular

No Qualifier

 

Pericardium

 

 

Open

Percutaneous

Percutaneous Endoscopic

 

Monitoring Device, Pressure Sensor

Monitoring Device

Cardiac Lead, Pacemaker

Cardiac Lead, Defibrillator

Cardiac Lead

 

 

No Qualifier

Pulmonary Trunk

Pulmonary Artery, Right

Pulmonary Artery, Left

Pulmonary Vein, Right

Pulmonary Vein, Left

Superior Vena Cava

Thoracic Aorta

 

 

 

Open

Percutaneous

Percutaneous Endoscopic

 

 

Monitoring Device, Pressure Sensor

Monitoring Device

Infusion Device

Intraluminal Device

 

 

 

 

No Qualifier

 


 

Tip No. 47

 

Thoracentesis documentation must indicate the drainage site as the right and/or left pleural cavity, per root operation table 0W9. Train physicians to document this information clearly in the operative report.

Section

0

Medical and surgical

Body System

W

Anatomical Regions, General

Operation

9

Drainage: Taking or letting out fluids and/or gases from a body part

 

Body Part

Approach

Device

Qualifier

 

Head

Cranial Cavity

Face

Oral Cavity and Throat

Upper Jaw

Lower Jaw

Neck

Chest Wall

Pleural Cavity, Right

Pleural Cavity, Left

Mediastinum

Pericardial Cavity

Abdominal Wall

Peritoneal Cavity

Retroperitoneum

Pelvic Cavity

Upper Back

Lower Back

Perineum, Male

Perineum, Female

 

 

 

 

 

 

 

 

 

 

 

 

Open

Percutaneous

Percutaneous Endoscopic

 

 

 

 

 

 

 

 

 

 

 

 

 

Drainage Device

 

 

 

 

 

 

 

 

 

 

 

No Qualifier

 

 

 

Tip No. 48

 

Hemodialysis must be documented as single or multiple filtration, per root operation table 5A1. Train the physician to document this level of detail in the operative report.

Section

5

Extracorporeal Assistance and Performance

Body System

A

Physiological Systems

Operation

1

Performance: Completely taking over a physiological function by extracorporeal means

 

 

Body Part

Approach

Device

Qualifier

 

Cardiac

 

Single

 

 

Output

 

Manual

 

Cardiac

Intermittent

 

Pacing

 

No Qualifier

 

Cardiac

Continuous

 

Output

Pacing

 

No Qualifier

 

Circulatory

 

Continuous

 

Oxygenation

 

Membrane

 

Respiratory

 

Single

 

Ventilation

 

Nonmechanical

 

Respiratory

 

Less than 24 Consecutive Hours

24-96 Consecutive Hours

Greater than 96 Consecutive Hours

 

Ventilation

 

No Qualifier

 

Biliary

Urinary

 

Single

Multiple

 

Filtration

 

No Qualifier

 

 


 

Tip No. 49

Train physicians to document in the operative report the specific carotid artery that is operated on for such procedures as a left common carotid endarterectomy. This information is needed for some of the root operation tables (such as 03C).

Section

0

Medical and surgical

Body System

3

Upper arteries

Operation

2

Extirpation: Taking or cutting out solid matter from a body part

 

Body Part

Approach

Device

Qualifier

 

Internal Mammary Artery, Right

Internal Mammary Artery, Left

Innominate Artery

Subclavian Artery, Right

Subclavian Artery, Left

Axillary Artery, Right

Axillary Artery, Left

Brachial Artery, Right

Brachial Artery, Left

Ulnar Artery, Right

Ulnar Artery, Left

Radial Artery, Right

Radial Artery, Left

Hand Artery, Right

Hand Artery, Left

Intracranial Artery

Common Carotid Artery, Right

Common Carotid Artery, Left

Internal Carotid Artery, Right

Internal Carotid Artery, Left

External Carotid Artery, Right

External Carotid Artery, Left

Vertebral Artery, Right

Vertebral Artery, Left

Face Artery

Temporal Artery, Right

Temporal Artery, Left

Thyroid Artery, Right

Thyroid Artery, Left

Upper Artery

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Open

Percutaneous

Percutaneous Endoscopic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No Device

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No Qualifier

 

 

 

 


 

Tip No. 50

Reference pathology reports to verify and code all bronchoscopic biopsy sites, because multiple codes may be required if the biopsy sites are assigned to different body parts (see root operation table 0BB).

Section

0

Medical and surgical

Body System

B

Respiratory system

Operation

B

Excision: Cutting out or off, without replacement, a portion of a body part

 

Body Part

Approach

Device

Qualifier

 

Trachea

Carina

Main Bronchus, Right

Upper Lobe Bronchus, Right

Middle Lobe Bronchus, Right

Lower Lobe Bronchus, Right

Main Bronchus, Left

Upper Lobe Bronchus, Left

Lingula Bronchus

Lower Lobe Bronchus, Left

Upper Lung Lobe, Right

Middle Lung Lobe, Right

Lower Lung Lobe, Right

Upper Lung Lobe, Left

Lung Lingula

Lower Lung Lobe, Left

Lung, Right

Lung, Left

Lungs, Bilateral

 

 

 

 

 

 

 

 

 

 

Open

Percutaneous

Percutaneous Endoscopic

Via Natural or Artificial Opening

Via Natural or Artificial Opening Endoscopic

 

 

 

 

 

 

 

 

 

 

 

 

No Device

 

 

 

 

 

 

 

 

 

 

Diagnostic

No Qualifier

 

 

 

Pleura, Right

Pleura, Left

Diaphragm, Right

Diaphragm, Left

 

 

Open

Percutaneous

Percutaneous Endoscopic

 

 

No Device

 

 

Diagnostic

No Qualifier

 

 

Read all previous coding tips

Read Coding Tips 91-100

Read Coding Tips 81-90

Read Coding Tips 71-80

Read Coding Tips 61-70

Read Coding Tips 51-60

Read Coding Tips 41-50

Read Coding Tips 31-40

Read Coding Tips 21-30

Read Coding Tips 11-20

Read Coding Tips 1-10

Notes

Melissa Myrick (MSA, RHIA) of BayCare Health System and Karen Youmans (MPA, RHIA, CCS) of YES HIM Consulting, Inc., “Innovative Strategies for Achieving High-Quality Medical Record Documentation in a Large Healthcare System,” 2013 ICD-10-CM/PCS Summit, Monday, April 22, 2013, Baltimore, Md.

Lolita M. Jones, RHIA, CCS

Lolita M. Jones, RHIA, CCS, is the principal of Lolita M. Jones Consulting Services (LMJCS), founded in October 1998 in Fort Washington, MD. Ms. Jones has over 25 years of experience in coding and consulting. She started preparing for the implementation of ICD-10-CM/PCS by going back to school. On September 12, 2010, Ms. Jones became an AHIMA-approved ICD-10-CM/PCS trainer.