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Basic ICD 10-CM/PCS and ICD-9-CM Coding, 2015 Edition

Basic ICD 10-CM/PCS and ICD-9-CM Coding, 2015 Edition. Chapter 2: Procedure Coding in ICD-9-CM and ICD-10-PCS. Learning Objectives. Review the chapter’s learning objectives A thorough understanding of the basic concepts of the ICD-9-CM procedure coding system is important

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Basic ICD 10-CM/PCS and ICD-9-CM Coding, 2015 Edition

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  1. Basic ICD 10-CM/PCS and ICD-9-CM Coding, 2015 Edition Chapter 2: Procedure Coding in ICD-9-CM and ICD-10-PCS

  2. Learning Objectives • Review the chapter’s learning objectives • A thorough understanding of the basic concepts of the ICD-9-CM procedure coding system is important • Other chapters in this book will include instruction on coding of procedures performed in specific body systems

  3. ICD-9-CM Volume 3: Procedures • ICD-9-CM classifies procedures in Volume 3 • Includes Alphabetic Index and Tabular List • Same format as Volumes 1 and 2 • ICD-9-CM procedures used for the coding of inpatient hospital procedures

  4. Volume 3: Procedures (continued) • Hospital inpatient procedures coded in range of procedure codes in categories 00–86 • Chapter 16 codes (87–99) may be used selectively for inpatient procedure coding according to hospital or facility coding policy

  5. Volume 3: Procedures (continued) • Hospital outpatient departments, physicians’ offices and other ambulatory care facilities use CPT-4 and HCPCS codes for procedures

  6. Tabular List • 17 chapters in ICD-9-CM Volume 3 • 16 chapters describe operations on specific body systems (codes 00–86) • One chapter includes miscellaneous diagnostic and therapeutic procedures (codes 87–99)

  7. Tabular List (continued) • Format of ICD-9-CM Volume 3 • Numeric codes only • 3- or 4-digit codes • 2 digits followed by a decimal point and one or two additional digits • 3rd or 4th digits provide further information about the site, procedure, or diagnosis

  8. ICD-9-CM Volume 3 Alphabetic Index • Listing of procedures, studies, tests, operations, therapies, and so on • Entries in the Alphabetic Index are more comprehensive than terms listed in the Tabular List • Trust the Alphabetic Index

  9. ICD-9-CM Volume 3 Main Terms • Terms listed in boldface type • Identify the type of procedure performed with subterms indented in alphabetic order • Main terms can include • Titles of operations • Procedure names • Nouns • Verbs • Main terms for procedures indicate an action performed, not a diagnosis or reason for the procedure

  10. ICD-9-CM Volume 3 Subterms • Subterms describe essential differences in the site, diagnosis, or surgical technique • Subterms may have subterms beneath • Verify all codes in the Tabular List—do not skip this step!

  11. ICD-9-CM Volume 3 Connecting Words • Subterms are used to reflect an instruction or an associated procedure • Subterms may begin with the words “as,” “by,” or “with” • Alphabetic subterms follow the connecting terms

  12. Eponyms in ICD-9-CM Volume 3 • Surgical procedures may be identified by eponyms, or names for their originators • May be indexed three ways: • Under the eponym • Under the main term “operation” or “procedure” • Under a main term or subterm describing the operation in terms of the action performed

  13. Conventions Used in ICD-9-CM Volume 3 • Code also • The phrase “code also” reminds the coder that additional procedure(s) must be coded when they are performed in addition to primary procedure • May reflect individual components of an operation or procedures performed together • May describe special adjunctive procedures or equipment

  14. Conventions Used in ICD-9-CM Volume 3 (continued) • Omit code • The phrase “omit code” is found only in volume 3 in both Alphabetic Index and Tabular List • This instruction indicates that no code is assigned, usually for exploratory part of procedure, operative approach, typical lysis of adhesions, or the closure of the procedure

  15. Conventions Used in ICD-9-CM Volume 3 (continued) • Omit code for the operative approach • When a definitive procedure (therapeutic or diagnostic) is performed, the operative approach is considered part of the procedure and is not coded • Coder knowledge of operative techniques is essential • If only an exploratory procedure is performed, the operative approach is used to describe it

  16. Endoscopic Procedures in ICD-9-CM Volume 3 • Open = Procedures that require an incision • Endoscopic = A less invasive procedure may be performed with a scope through tiny incisions into a cavity or joint and uses videoscopic guidance

  17. Endoscopic Procedures (continued) • If an endoscopic procedure is performed as the approach so that a more definitive procedure can be performed, the endoscopic portion is not coded as it is the “approach”

  18. Endoscopic Procedures (continued) • If an endoscopic procedure is unsuccessful, the surgeon may complete the procedure through an “open” approach. • If this is the case, only the “open” procedure is coded. • Diagnosis code V64 category explains the “conversion” from endoscopic to open.

  19. Endoscopic Procedures (continued) • Main term “endoscopy” or the more specific term describing the procedure may be used for the Alphabetic Index • Specific procedure codes exist to describe various endoscopic procedures

  20. Endoscopic Procedures (continued) • If the endoscope is passed through more than one body cavity, the code for the endoscopy should identify the most distant site only

  21. Slanted brackets [ ] in ICD-9-CM Volume 3 • Slanted brackets found in the Alphabetic Index or in the Tabular List indicate that two codes for closely related procedures are required • This convention means both codes must be used and sequenced as listed

  22. Aborted Surgery or Procedure in ICD-9-CM Volume 3 • When a procedure was started but not completed, code the procedure to the extent it was performed • Coding rule = “Code as far as it goes” • Cavity entered = code exploratory procedure • Incision made = code incision only • No procedure = add V64 diagnosis code for the reason the procedure was not completed

  23. Incomplete Procedures in ICD-9-CM Volume 3 • When a planned procedure is started but not completed, code to the following principles: • If cavity/space entered, code to exploration of site • If endoscopic approach is used but no definitive procedure performed, code the endoscopy only • If only an incision made, code to incision of site • When the procedure does not involve an incision, no procedure code is assigned

  24. Failed Procedures in ICD-9-CM Volume 3 • Some procedures are considered to have failed if the procedure did not achieve the desired outcome or result • This does not influence code assigned • The procedure performed is the procedure coded

  25. Biopsy and Surgery in ICD-9-CM Volume 3 • If a biopsy is performed and is followed by a more extensive surgery during the same operative episode, code the surgical procedure that is the more extensive surgery first, followed by the biopsy code • An “open” biopsy requires an incision—the open biopsy code includes the incision

  26. Closed Biopsy Procedure in ICD-9-CM Volume 3 • A closed biopsy is performed percutaneously, endoscopically, or through the use of a needle • If a needle or percutaneous biopsy is performed via an open procedure, code both the open procedure and the needle biopsy

  27. Endoscopic Biopsies in ICD-9-CM Volume 3 • When ICD-9-CM provides one code to identify both the biopsy and the endoscopy, use this one code • When ICD-9-CM does not provide a code to identify both the biopsy and the endoscopy, assign two codes, listing first the endoscopy code

  28. Bilateral Procedure Coding in ICD-9-CM Volume 3 • ICD-9-CM may provide a single code to identify that a bilateral procedure was performed (A bilateral procedure code is used only once) • However, when ICD-9-CM does not provide a code for a “bilateral” procedure, the code for the procedure is listed twice

  29. Basic Steps for ICD-9-CM Volume 3 Procedure Coding 1. Identify all main terms included in the procedural statement 2. Locate each main term in the Alphabetic Index 3. Refer to any subterms indented under the main term

  30. Basic Steps for ICD-9-CM Volume 3 Procedure Coding (continued) 4. Follow cross-reference instructions if the needed code is not located under the first main entry 5. Verify the code selected from the Index in the Tabular List—do not skip this step!

  31. Basic Steps for ICD-9-CM Volume 3 Procedure Coding (continued) 6. Read and be guided by all instructional terms 7. Continue coding until all procedures are identified 8. When the same procedure is performed bilaterally and ICD-9-CM does not identify the code as a bilateral procedure, assign the code for the procedure twice

  32. ICD-9-CM Volume 3 Procedure Coding Guidelines • Each healthcare facility should specify in its coding policies what procedures will be assigned codes. • Some healthcare facilities do not assign codes to many diagnostic and nonsurgical procedures.

  33. Selection of Principal Procedure using ICD-9-CM Volume 3 • Following instructions should be applied in the selection of the principal procedure • Coding Clinic Fourth Quarter 2012 provided this information as well as clarification on the importance of the relation of the principal procedure to the principal diagnosis when more than one procedure is performed

  34. Selection of Principal Procedure using ICD-9-CM Volume 3 continued • Procedure performed for definitive treatment of both principal diagnosis and secondary diagnosis • Sequence procedure performed for definitive treatment most related to the principal diagnosis as the principal procedure

  35. Selection of Principal Procedure using ICD-9-CM Volume 3 continued • Procedure performed for definitive treatment and diagnostic procedure performed for both principal diagnosis and secondary diagnosis • Sequence procedure performed for definitive treatment most related to principal diagnosis as principal procedure

  36. Selection of Principal Procedure using ICD-9-CM Volume 3 continued • A diagnostic procedure was performed for the principal diagnosis and a procedure is performed for definitive treatment of a secondary diagnosis • Sequence diagnostic procedure as principal procedure, since the procedure most related to the principal diagnosis takes precedence

  37. Selection of Principal Procedure using ICD-9-CM Volume 3 continued • No procedures performed that are related to principal diagnosis; procedures performed for definitive treatment and diagnostic procedures were performed for secondary diagnosis. • Sequence procedure performed for definitive treatment of secondary diagnosis as principal procedure, since there are no procedures (definitive or nondefinitive treatment) related to principal diagnosis.

  38. Introduction to ICD-10-PCS Inpatient procedure coding replacing Volume 3 of ICD-9-CM on October 1, 2015 ICD-10-PCS is unique to United States Developed by 3M Health Information Systems under contract with CMS Initially released in 1998 with updates the following years

  39. ICD-10-PCS Designed and developed to meet healthcare needs for a procedure code system Codes constructed from flexible code components (values) using tables; each individual number of letter is known as a value Codes are alphanumeric All codes are seven characters long

  40. The ICD-10-PCS Code Seven Characters, Alphanumeric 1 – section of ICD-10-PCS 2 – body system 3 – root operation 4 – body part 5 – approach 6 – device 7 – qualifier

  41. ICD-10-PCS Code Each of the 7 characters have a defined meaning Character 1: Section – first character determines the broad category or section where the code is located. In the first section, Medical and Surgical, all begin with 0 or zero Character 2: Body System – defines the body system which is the general physiological system or anatomic region involved

  42. ICD-10-PCS Code Character 3: Root Operation – the objective of the procedure being performed Character 4: Body Part – the body part of specific anatomical site where the procedure is performed

  43. ICD-10-PCS Code Character 5: Approach – the technique used to reach the operative site, 7 approaches defined Character 6: Device – depending on the procedure there may or may not be a device left in place at the end of the procedure Character 7: Qualifier – defined for a particular code, an additional attribute of the procedure

  44. ICD-10-PCS Classification System • ICD-10-PCS is composed of 16 sections with section values using • Numbers 0 through 9 • Letters B through D and Letters F through H • 16 sections contained within three main sections: • Medical and Surgical section • Medical and Surgical related section • Ancillary section

  45. ICD-10-PCS • First section, Medical and Surgical section, contains the majority of procedures typically performed in an inpatient setting. • First Character • All procedures begin with the section value of 0 (zero)

  46. ICD-10-PCS • Second section, Medical and Surgical-related section, include procedures such as • Obstetrics, Placement, Administration, Measurement and Monitoring, Extracorporeal Assistance and Performance, Extracorporeal Therapies, Osteopathic, Other procedures, and Chiropractic • All procedures begin with the section value of 1 through 9 (numbers)

  47. ICD-10-PCS • Third section, Ancillary section, include procedures such as • Imaging, Nuclear Medicine, Radiation Oncology, Physical Rehabilitation and Diagnostic Audiology, Mental Health and Substance Abuse • All procedures begin with the section value of B through D and F through H (letters)

  48. ICD-10-PCS Medical-Surgical Section First character = Medical Surgical Section (0) Second character = Body System 31 body systems identified Some customary body systems have multiple-body system values, for example, circulatory and musculoskeletal have multiple values Values of 0-9, B, C, D, F, G, H, J, K, L, M, N, P, Q, R, S, T, U, V, W, X, Y, Z Third character = Root Operations 31 root operations, each representing the specific objectives of the procedure Nine groups of procedures See textbook for the nine groups and root operations within each group

  49. ICD-10-PCS Medical-Surgical Section Fourth character = Body Part Represents the specific part of the body system on which surgery is performed; may specify laterality. Examples, Lower extremities (body system), Left foot (body part) Fifth character = Approach Technique used to reach the site of the procedure. Seven different approaches Open; Percutaneous; Percutaneous endoscopic; Via Natural or Artificial Opening; Via Natural or Artificial Opening Endoscopic; Via Natural or Artificial Opening Endoscopic with Percutaneous Endoscopic Assistance; and External

  50. ICD-10-PCS Medical-Surgical Section Sixth character = Device Specifies the device that remains after the procedure is completed Used with certain procedures Four general types of devices: Biological or synthetic material that takes the place of all or a portion of a body part; Biological or synthetic material that assists or prevents a physiological function; Therapeutic material; Mechanical or electronic applicance Seventh character = Qualifier Used with certain procedures to define an additional attribute Unique values for individual procedures as needed, for example, identify the destination site in a bypas

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