36 terms

ICD-10-PCS Coding Guidelines


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ICD-10-PCS codes are composed of seven characters. Each character is an axis of classification that specifies information about the procedure performed. Within a defined code range, a character specifies the same type of information in that axis of classification.
One of 34 possible values can be assigned to each axis of classification in the seven character code: they are the numbers 0-9 and the letters of the alphabet (except I,O). The number of unique values used in the axis of classification differs as needed
The valid values of an axis of classification can be added to as needed
As with words in their context, the meaning of any single value is a combination of its axis of classification and any preceding values on which it may be dependent
As the system is expanded to become increasingly detailed, over time more values will depend on preceding values for their meaning
The purpose of the alphabetic index is to locate the appropriate table that contains all information necessary to construct a procedure code. The PCS tales should always be consulted to find the most appropriate valid code
It is not required to consult the index first before proceeding to the tables to complete a code. A valid code may be chosen directly from the tables
All seven characters must contain a valid values to be a valid procedure code. If the documentation is incomplete for coding purposes, the physician should be queried for the necessary information
Within PCS table, valid codes include all combinations of choices in characters 4-7 contained in the same row of the table
"And", when used in a code description, means "and/or."
Many of the terms used to construct PCS codes are defining within the system. It is the coder's responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCs terms is clear.
The procedure codes in general anatomical regions body systems should only be used when the procedure is performed on an anatomical region rather than a specific body part (root operations Control and Detachment, drainage of a body cavity) or on the rare occasion when no information is available to support assignment of a code to a specific body part
Where the general body part values "upper" and "lower" are provided as an option in the Upper Arteries, Lower Arteries, Upper Veins, Lower Veins, Muscles and Tendons body systems, "upper" or "lower" specifies body parts located above or below the diaphragm, respectively
In order to determine the appropriate root operation, the full definition of the root operation as contained in the PCS Tables must be applied
Components of a procedure specified in the root operation definition and explanation are not coded separately. Procedural steps necessary to reach the operative site and close the operative site, including anastomosis of a tubular body part, are also not coded separately
During the same operative episode, multiple procedures are coded if:
During the same operative episode, multiple procedures are coded if:
The same root operation is performed on different body parts as defined by distinct values of the body part character
During the same operative episode, multiple procedures are coded if:
The same root operation is repeated at different body sites that are included in the same body part value
During the same operative episode, multiple procedures are coded if:
Multiple root operations with distinct objectives are performed on the same body part
During the same operative episode, multiple procedures are coded if:
The intended root operation is attempted using one approach but it is converted to a different approach
If the intended procedure is discontinued, code the procedure to the root operation performed. If a procedure is discontinued before other root is performed, code the root operation inspection of the body part or anatomical region inspected
Biopsy procedures are coded using the root operations Excision, Extraction or Drainage and the qualifier Diagnostic. The qualifier Diagnostic is used only for biopsies
If a diagnostic Excision, Extraction, or Drainage procedure is followed by a more definitive procedure, such as Destruction, Excision, or Resection at the same procedure site, both the biopsy and the more definitive treatment are coded.
If the root operations Excision, Repair, or Inspection are performed on overlapping layers of the musculoskeletal system, the body part specifying the deepest layer is coded.
Bypass procedures are coded by identifying the body part bypassed "from" and the body part "to". The 4th character body part specifies the body part bypassed from, and the qualifier specifies the body part bypassed to
Coronary arteries are classified by number of distinct sites treated, rather than number of coronary arteries or anatomical name or of a coronary artery. Coronary artery bypass procedures are coded differently from other bypass procedures as described in the previous guideline. Rather than identifying the body part bypassed from, the body part identifies the number of coronary artery sites bypassed to, and the qualifier specifies the vessel bypassed from
If multiple coronary artery sites are bypassed, a separate procedure is coded for each coronary artery site that uses a different device or qualifier.
The root operation Control is defined as "Stopping, or attempting to stop, postprocedural bleeding". If an attempt to stop postprocedural bleeding is initially unsuccessful. and to stop the bleeding requires performing any of the definitive root operations Bypass, Detachment, Excision, Reposition, Replacement, or Resection, then that root operation is coded instead of Control.
PCS contains specific body parts for anatomical subdivisions of a body part such as lobes of the lungs or liver and regions of the intestine. Resection of the specific body part is coded whenever all of the body part is cut out or off, rather than coding Excision of a less specific body part
If an autograph is obtained from a different body part in order to complete the objective of the procedure, a separate procedure is coded
The body part coded for spinal vertebral joints rendered immobile by a spinal fusion procedure is classified by the level of the spine. There are distinct body part values for a single vertebral joint for multiple vertebral joints at each spinal level
If multiple vertebral joints are fused, a separate procedure is coded for each vertebral joint that uses a different device and or qualifier.
Combinations of devices and materials are often used on a vertebral joint to render the joint immobile. When combinations of devices are used on the same vertebral joint, the device value coded for the procedure is as follows:
- if an interbody fusion device is used to render the joint immobile (alone or containing other material, like bone graft), the procedure is coded with the device value Interbody Fusion Device
- if bone graft is the only device used to render the joint immobile, the procedure is coded with the device value Nonautologous Tissue Substitute or Autologous Tissue Substitute
- if a mixture of autologous and nonautologous bone graft (with or without biological or synthetic extenders or binders) is used to render the joint immobile, code the procedure with the device value Autologous Tissue Substitute
Inspection of a body part(s) performed to achieve the objective of a procedure is not coded separately
If multiple tubular body parts are inspected, the most distal body part inspected is coded. If multiple non-tubular body parts in a region are inspected, the body part that specifies the entire area inspected is coded.
When both an Inspection procedure and another procedure are performed on the same body part during the same episode, if the inspection procedure is performed using a different approach from the other procedure, the Inspection procedure is coded separately