ICD-10-PCS

1. ICD-10-PCS Beginning The Journey

2. ICD-10-PCS – Structure ICD-9-CM ICD-10-PCS • ICD-9-CM has 3-4 characters • All characters are numeric • All codes have at least 3 characters • ICD-10-PCS has 7 characters • Each can be either alpha or numeric • Numbers 0-9; letters A-H, J-N, P-Z • Alpha characters are not case-sensitive • Each code must have 7 characters ICD-10 AHIMA

3. ICD-10-PCS - Structure ICD-9-CM ICD-10-PCS . X X X X 1 2 4 3 0 3 X 1 X D 0 E X 0 B H 5 0 F X 7 8 8 X Z 3 X 0 4 X Z X ICD-10 AHIMA

4. WHAT IS A ROOT OPERATION???? THE OBJECTIVE OR ACTION OF THE PROCEDURE

5. 31 MEDICAL & SURGICAL ROOT OPERATIONS There is a specific definition for each one of these roots ICD-10-PCS uses terminology that coders are not accustomed to seeing on a chart The purpose of this training is to help the coder smoothly transition to the new root operation and their meanings

6. SURGICAL & MEDICAL ROOT OPERATIONS (31)

7. ICD-10-PCS - Structure Characters (Med/Surg) 1 2 3 4 5 6 7 Root Operation Qualifier Section Approach Body System Body Part Device ICD-10 AHIMA

8. First Character of the Procedure Code -Section 0 - Medical and Surgical 1 – Obstetrics 2 – Placement 3 - Administration 4 – Measurement and Monitoring 5 – Extracorporeal Assistance and Performance 6 – Extracorporeal Therapies 7 – Osteopathic 8 – Other Procedures 9 – Chiropractic B – Imaging C – Nuclear Medicine D – Radiation Oncology F – Physical Rehabilitation and Diagnostic Audiology G – Mental Health H – Substance Abuse Treatment

9. Medical and Surgical section Largest of the 16 sections Same definition or meaning Section B–D and F-H comprise the Ancillary section of ICD-10-PCS

10. Sec Second Character- Body System General physiological system or anatomical region involved

11. Third Character – Root Operation Objective of the procedure 31 Root Operations

12. Fourth Character – Body Part Defines the body part or specific anatomical site where the procedure was performed This is different from character 2 which provides the general Body System There are 34 possible body part values in each body system

13. Fifth Character - Approach Defines the approach, or the technique used to reach the procedure site There are seven different approach values in the Medical and Surgical section

14. Sixth Character - Devices Identified devices that remain after the procedure is completed Remember that all codes require seven characters The default value to indicate that NO device was involved is Z

15. Seventh Character - Qualifier Qualifier for the code that provides additional information about a specific attribute of the procedure These qualifiers may have a narrow application, to a specific root operation, body system or body part Most procedures will not have an applicable qualifier. The default value for NO qualifier is a Z

16. EXAMPLE CODE 0LB50ZZ Excision of right lower arm and wrist tendon, open” 0 = Section – Medical and Surgical L = Body Section - Tendons B = Root Operation- Excision 5 = Body Part – Lower arm and wrist tendon, right 0 = Approach - Open Z = Device – No Device Z = Qualifier – No Qualifier

17. CODERS MUST LEARN NEW TERMINOLOGY It is the coder’s responsibility to determine which root operation the documentation in the medical record equates to in the PCS definitions

18. PHYSICIAN TERMINOLOGY MAY NOT CHANGE • The physician is not expected to use the root terms provided in PCS code description Nor Is the coder required to query the physicians when the correlation between the documentation and the defined PCS term is clear.

19. EPONYMS ARE GONE IN ICD 10 PCS Billroth I procedure equates to anastomosis

20. QUESTIONS