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Module 04 Assignment - ICD-10-PCS Coding Principles and Code Build Process
Overview: There are 3 parts to this assignment. Each part of the assignment addresses a specific aspect of ICD-10-PCS coding. To code accurately using the ICS-10-PCS system requires the ability to understand and apply the coding principles to clinical documentation by following the designated code build process.
Part A: ICD-10-PCS Identify Coding Guidelines
The ICD-10-PCS system includes specific conventions and coding guidelines or “rules” which provide instruction on how to accurately construct the codes. This portion of the assignment will provide an opportunity to become more familiar with the guidelines to be used in the determination of the appropriate PCS code. Instructions: Utilize the ICD-10-PCS Official Coding Guidelines presented in the front of the ICD-10-PCS Code Book to match the narrative in the assignment for Part A. Steps: For each coding guideline narrative,
- Read the narrative in Column 1-Part A in the table below.
- Match the coding guideline(s) narratives in Column 1-Part A with the Official Coding Guidelines found in the front of the ICD-10- PCS Code Book.
- Enter the alphanumeric label identifier from the Official Coding Conventions/Guideline(s) in Column 2-Part A of the table in correlation to the coding guideline narrative in Column 1-Part A. If there is more than one applicable Coding Convention or Guideline for the narrative, enter both guideline labels in Column 2-Part A corresponding to the narrative in Column 1-Part A.
- Reference both A and B conventions and guidelines from The Official Coding Guidelines in the front of the ICD-10-PCS Code Book.
Table for Part A - Identify the Official Coding Guideline
Column 1-Part A Column 2-Part A ICD-10-PCS Coding Guidelines Coding Guideline Identifiers Example: ICD-10-PCS codes are always composed of 7 characters.
A
1A. It is not required that the provider document using the exact PCS terms. The coder has the responsibility to correlate the clinical documentation stated by the provider to the correct Root Operation definition without querying the provider for clarification.
A
2A. The Code Tables in the code book may be accessed directly or the Alphabetic Index may be used to locate the correct table. It is optional to use the Alphabetic Index, but the PCS Code Tables must always be consulted to determine a valid code.
A
3A. Each of the 7 characters of a PCS codes has a specific “value”. The character can be represented by a number value of 0 – 9 or an alphabetic letter value with the exception of alpha characters O and I to avoid confusion with 0 (zero) and 1 (one). Use of and O or I in a PCS code results in an invalid code. 4A. For a PCS code to be valid, the combinations of the 4 th^ – 7 th^ character values must all be obtained from the same row in the PCS Code Tables.
A
5A. Components of a procedure that are stated in the Root Operation definition and explanation are NOT coded separately. Also, any procedural steps necessary to reach the operative site and close the operative site, including anastomosis of a tubular body part, are NOT coded separately. B3.1b 6A. Multiple procedures are coded if during the same operative encounter, the same root operation is performed on different body parts as defined by distinct values of the body part character. B3.2a 7A. If a procedure is performed on a portion of a body part that does not have a separate body part value, code the body part value corresponding to the whole-body part.
B4.
8A. The Root Operations Excision, Extraction and Drainage are used for Biopsy procedures along with the Qualifier X-Diagnostic. The X Qualifier is only used for procedures such as biopsies, where the intent of the procedure is to remove a portion of the body part for the purpose of analysis. Documentation that merely states the specimen was sent to Pathology does NOT equate to a diagnostic intent as this is a standard procedure for all removed tissue. B3.4a
18A. The Root Operation Control is defined as “Stopping or attempting to stop post-procedural or other acute bleeding.” If an attempt to stop the bleeding is initially unsuccessful and to stop the bleeding requires a more definitive root operation such as Bypass, Detachment, Excision, Extraction, Reposition, Replacement or Resection, then the more definitive root operation is coded instead of Control.
B3.
19A. Reduction of a displaced fracture is coded to the Root Operation Reposition. The application of a cast or splint in conjunction with a Reposition procedure is not coded separately. Treatment of a non-displaced fracture is coded to the procedure performed.
B3.
20A. In the Root Operation Release, the body part value to be coded is the body part being freed and not the tissue being manipulated or cut to free the body part that is entrapped.
B3.
Part B: ICD-10-PCS Apply Coding Guidelines to Clinical Documentation
To accurately assign codes in the ICD-10-PCS coding system, the Official Coding Guidelines need to be applied to the clinical documentation as stated in operative notes. The second part of the assignment requires interpretation of the clinical documentation and application of the coding guideline(s) in order to guide the coder in determining the appropriate PCS code. Instructions: In this portion of the assignment, Column 1-Part B provides scenarios that are to be aligned with the appropriate coding guidelines from the Official Coding Guidelines. Steps:
- Read the narrative scenario in Column 1-Part B in the table below.
- Identify the appropriate coding guideline(s) for each scenario and enter the alphanumeric label identifier(s) for the Official Coding Guideline in Column 2-Part B.
Table for Part B - Apply Guidelines to Scenarios
Column 1-Part B Column 2-Part B Scenarios Indicate Applicable Coding Guideline Identifier
Example: 0DTJ0Z only 6 characters is an invalid code per which coding guideline A 1B. A procedure performed on the skin overlying the wrist joint is coded to the Lower Arm B4. 2B. A procedure performed on the alveolar process of the mandible is coded to the mandible body part B4. 3B. Excisional biopsy of the right breast B3.2a 4B. The provider states that he performed the removal of the entire gallbladder B3. 5B. Resection of the hip joint in preparation for a total hip replacement A 6B. The coder accessed the PCS Code tables directly bypassing the Alphabetic Index B3.1b
7B. Code assigned: O DTJ0ZZ – Section value “O” is invalid per which coding guideline A
8B. Excision of a lesion in the ascending colon and excision of a lesion in the rectum B3.2a 9B. Excisional debridement through the skin, subcutaneous tissue to the muscle B3. 10B. Valid Code: 0HHW01Z vs Invalid Code: 0HHWXNZ – character values 4 – 7 must come from the same row in the Code Book
A
11B. 0UL 7 4CZ – Body Part value is an example of which coding guideline B4.
12B. Laparoscopic appendectomy converted to open appendectomy B3.2d 13B. Femoropopliteal Bypass Body Part and Qualifier values per guideline B3.6a 14B. Esophagoscopy used in the performance of dilation of the esophagus 83.11a 15B. Device value in a procedure performed to dilate the urethra using a 32 French calibrator B6.1b 16B. Body Part in an EGD (esophagogastroduodenoscopy) exploration via entry through the mouth to the duodenum B3.11b 17B. Root Operation for post-operative hemorrhage with cauterization of a bleeder to stop the bleeding B3.
- Based on the procedural statement, determine which definition is the best match. Enter that Root Operation and your rationale (reason) for that choice.
- State the first 3 characters of the PCS code for the Root Operation identified in the Alphabetic Index.
OFT
- Locate that table in the PCS Code Book Code Tables. Indicate the page number of the Code Table.
- Based on the procedure definition, state the body part and the corresponding 4th^ character value for Body Part from the code table.
- Research the term for the type of approach stated in the procedural statement. State the definition and your source. a minimally invasive procedure that uses small incisions and specialized tools to remove the gallbladder.
- Based on the information from #9, state the Approach and its definition along with the character value for the 5th^ character Approach selected from the code table.
- Based on the procedural statement, is a Device to be coded? Why or why not? State the code character value and description for the 6 th^ character DEVICE.
- Based on the procedural statement, enter the 7 th^ character value and code character for the Qualifier from the code table.
- State the final 7-character PCS Code as determined via the PCS Code Book code table
0FT44Z Z
- Complete the code character table (below) by entering the character descriptions and character values for the code stated in #14 (above). An example of a completed table is shown at the bottom of the page. Character 1 Value Character 2 Value Character 3 Value Character 4 Value Character 5 Value Character 6 Value Character 7 Value Section Body System Root Operation Body Part Approach Device Qualifier Example of a Medical and Surgical Code: 0DBH8ZX Character 1 Character 2 Character 3 Character 4 Character 5 Character 6 Character 7
Value Value Value Value Value Value Value Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical (0) Gastrointestinal (D) Excision (B) Cecum (H) Via a natural orifice endoscopic (8) None (Z) Diagnostic (X)
