July 16, 2013

One Hundred Tips for ICD-10-PCS Coding: Tips 61-70

By

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 newly released 2014 ICD-10-PCS root operation tables and resources, go online to http://www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-PCS.html.

Tip No. 61

Coding professionals must reference medical record documentation or manufacturers’ reference materials to determine if an autologous or nonautologous tissue substitute is of full thickness or partial thickness. This information is required in ICD-10-PCS root operation table 0HR.

Examples of tissue substitutes include:

Apligraf® - A composite of epidermis and dermis (i.e. full thickness).

Alloderm® - Dermis only (partial thickness).

Integra® - Biosynthetic dermis (partial thickness).

If the tissue substitute components are not documented in the medical record, and only the brand name is provided, research this information on the manufacturers’ websites and incorporate it into your facility’s internal coding guidelines. It is important that all coding specialists have access to this information when coding.

Below is an excerpt from table 0HR (this is not the entire table).

Section

0

Medical and surgical

Body System

H

Skin and breast

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

 

0 Skin, Scalp

1 Skin, Face

2 Skin, Right Ear

3 Skin, Left Ear

4 Skin, Neck

5 Skin, Chest

6 Skin, Back

7 Skin, Abdomen

8 Skin, Buttock

9 Skin, Perineum

A Skin, Genitalia

B Skin, Right Upper Arm

C Skin, Left Upper Arm

D Skin, Right Lower Arm

E Skin, Left Lower Arm

F Skin, Right Hand

G Skin, Left Hand

H Skin, Right Upper Leg

J Skin, Left Upper Leg

K Skin, Right Lower Leg

L Skin, Left Lower Leg

M Skin, Right Foot

N Skin, Left Foot

 

 

 

 

 

 

 

 

 

 

X External

 

 

 

 

 

 

 

 

 

7 Autologous Tissue Substitute

K Nonautologous Tissue Substitute

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3 Full Thickness

4 Partial Thickness

 

 


 

Tip No. 62

In some root operation tables (such as 0U2), there are body-part combinations listed with a single body-part value, for example:

  • “Uterus and cervix”

  • “Vagina and cul-de-sac”

According to ICD-10-PCS guideline A10, “’and,’ when used in a code description, means ‘and/or.’” For example, “uterus and cervix” means “uterus and/or cervix.”

When selecting a combination body-part value, please make sure at least one of the body parts is involved in the procedure that is being coded.

Section

0

Medical and surgical

Body System

U

Female reproductive system

Operation

2

Change: Taking out or off 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

 

Body Part

Approach

Device

Qualifier

3 Ovary

8 Fallopian Tube

M Vulva

 

 

X External

 

0 Drainage Device

Y Other Device

 

Z No Qualifier

 

D Uterus and Cervix

 

X External

 

0 Drainage Device

H Contraceptive Device

Y Other Device

 

Z No Qualifier

 

H Vagina and Cul-de-sac

 

X External

 

0 Drainage Device

G Intraluminal Device, Pessary

Y Other Device

 

Z No Qualifier

 

Tip No. 63

In some root operation tables (such as 10J), retained and ectopic products of conception are distinguished from traditional products of conception.

Section

1

Obstetrics

Body System

0

Pregnancy

Operation

J

Inspection: Visually and/or manually exploring a body part

 

 

Body Part

Approach

Device

Qualifier

 

0 Products of Conception

1 Products of Conception, Retained

2 Products of Conception, Ectopic

 

0 Open

3 Percutaneous

4 Percutaneous Endoscopic

7 Via Natural or Artificial Opening

8 Via Natural or Artificial Opening Endoscopic

X External

 

 

Z No Device

 

 

Z No Qualifier

 

 


 

Tip No. 64

Meet with staff experts to become familiar with the radiology information system (RIS) that is being used in your facility in order to identify the location of key data that is needed for ICD-10-PCS coding.

Examples of key radiology data that is needed in some of the ICD-10-PCS tables include:

  • Fluoroscopy contrast: high osmolar, low osmolar, other, none.

  • Computerized tomography (CT) and magnetic resonance imaging (MRI) contrast: unenhanced, enhanced, none.

If key radiology data currently is stored in the RIS and is not available in the medical record, implement the appropriate process changes to document or import this information into the medical record, because it must be available to justify the ICD-10-PCS code assignments.

Section

B

Imaging

Body System

2

Heart

Operation

2

Computerized tomography (CT Scan): Computer-reformatted digital display of multiplanar images developed from the capture of multiple exposures of external ionizing radiation

 

Body Part

Contrast

Qualifier

Qualifier

1 Coronary Arteries, Multiple

3 Coronary Artery Bypass Grafts, Multiple

6 Heart, Right and Left

 

 

0 High Osmolar

1 Low Osmolar

Y Other Contrast

 

0 Unenhanced and Enhanced

Z None

 

Z None

 

1 Coronary Arteries, Multiple

3 Coronary Artery Bypass Grafts, Multiple

6 Heart, Right and Left

 

Z None

 

2 Intravascular Optical Coherence

Z None

 

Z None

 

Tip No. 65

For venous ultrasounds, root operation table B54 provides qualifiers for intravascular ultrasound, ultrasound guidance, and none (i.e., traditional ultrasound). Please make sure these ultrasounds are documented appropriately for accurate ICD-10-PCS coding.

Tip No. 66

There is no specific ICD-10-PCS table for discontinued procedures. ICD-10-PCS guideline B3.3 states:

“If the intended procedure is discontinued, code the procedure to the root operation performed. If a procedure is discontinued before any other root operation is performed, code the root operation ‘Inspection of the body part or anatomical region inspected.’”

In order to track the discontinued nature of a procedure, strongly consider reporting the appropriate ICD-10-CM “Z” code:

Z53.01 Procedure and treatment not carried out due to patient smoking

Z53.09 Procedure and treatment not carried out because of other contraindication

Z53.1 Procedure and treatment not carried out because of patient's decision for reasons

of belief and group pressure

Z53.20 Procedure and treatment not carried out because of patient's decision for unspecified reasons

Z53.21 Procedure and treatment not carried out due to patient leaving prior to being seen

by healthcare provider

Z53.22 Procedure and treatment not carried out because of patient's decision for other

reasons

Z53.29 Procedure and treatment not carried out because of patient's decision for other

reasons

Z53.8 Procedure and treatment not carried out for other reasons

Z53.9 Procedure and treatment not carried out, unspecified reason

 


 

Tip No. 67

In ICD-10-PCS, the pharmacotherapy table HZ9 classifies the use of replacement medications for the treatment of addiction; the monitoring and adjusting of replacement medications used for the treatment of addiction is coded to medication management table HZ8.

Tip No. 68

A medical record for a patient whose seizure episode is treated with electroconvulsive therapy (ECT) must contain the following documentation:

  • Unilateral or bilateral ECT;

  • Single or multiple seizure treatment using the ECT.

Section

G

Mental health

Body System

Z

None

Operation

B

Electroconvulsive therapy: The application of controlled electrical voltages to treat a mental health disorder

 

Qualifier

Qualifier

Qualifier

Qualifier

0 Unilateral-Single Seizure

1 Unilateral-Multiple Seizure

2 Bilateral-Single Seizure

3 Bilateral-Multiple Seizure

4 Other ElectroconvulsiveTherapy

 

 

 

Z None

 

 

Z None

 

 

Z None

 

Tip No. 69

Educate surgeons about the importance of clearly documenting the anatomical location used to harvest a graft. According to ICD-10-PCS guideline B3.9, “if an autograft is obtained from a different body part in order to complete the objective of the procedure, a separate procedure is coded.”

Tip No. 70

Fetal or in-utero surgery is coded to the “products of conception” body part.

For example, Open in-utero repair of congenital diaphragmatic hernia would be coded as 10Q00ZK.

Section

1

Obstetrics

Body System

0

Pregnancy

Operation

Q

Repair: Restoring, to the extent possible, a body part to its normal anatomic structure and function

 

 

Qualifier

Qualifier

Qualifier

Qualifier

 

0 Products of Conception

 

 

 

0 Open

3 Percutaneous

4 Percutaneous Endoscopic

7 Via Natural or Artificial Opening

8 Via Natural or Artificial Opening Endoscopic

 

 

 

Y Other Device

Z No Device

 

 

 

E Nervous System

F Cardiovascular System

G Lymphatics and Hemic

H Eye

J Ear, Nose and Sinus

K Respiratory System

L Mouth and Throat

M Gastrointestinal System

N Hepatobiliary and Pancreas

P Endocrine System

Q Skin

R Musculoskeletal System

S Urinary System

T Female Reproductive System

V Male Reproductive System

Y Other Body System

 

 

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

Click to return to the enews index

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.