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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
Page 2 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
Page 4 (specify in the 7th^ Character Qualifier Value). Coronary artery bypass procedures are coded differently than other bypass procedures. The Body Part identifies the number of coronary arteries bypass to and the Qualifier specifies the vessel bypassed from. 12A. Root Operations Excision, Extraction, Repair or Inspection performed on overlapping layers of the musculoskeletal system are coded to the Body Part specifying the deepest layer.
B3.
13A. Inspection of a body part(s) performed to accomplish the intent or objective of the procedure is not coded separately. B3.11a
Page 5 14A. If multiple tubular body parts are inspected, the most distal body part (furthest from the starting point of the inspection) is coded. B3.11b 15A. Procedures performed within an orifice on structures that are visible without the aid of any instrumentation are coded to the Approach External. Procedures performed indirectly by the application of external force through and intervening body layers are coded to the Approach External. B5.3a 16A. A device is coded only if the device remains after the procedure is completed. Materials such as sutures, ligatures, radiological markers and temporary post-operative wound drains are considered integral to the procedure and are not coded as devices. B6.1b 17A. If a procedure is performed on the skin, subcutaneous tissue or fascia overlying a joint, the procedure is coded to a specific body part.
B4.
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
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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 B3.2a 2B. A procedure performed on the alveolar process of the mandible is coded to the mandible body part B1.1a 3B. Excisional biopsy of the right breast B3.4a 4B. The provider states that he performed the removal of the entire gallbladder B5.2b 5B. Resection of the hip joint in preparation for a total hip replacement B3.1b 6B. The coder accessed the PCS Code tables directly bypassing the Alphabetic Index A
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 B3.1a
12B. Laparoscopic appendectomy converted to open appendectomy B3. 13B. Femoropopliteal Bypass Body Part and Qualifier values per guideline B3.1a, B3. 14B. Esophagoscopy used in the performance of dilation of the esophagus B3. 15B. Device value in a procedure performed to dilate the urethra using a 32 French calibrator B4.1a 16B. Body Part in an EGD (esophagogastroduodenoscopy) exploration via entry through the mouth to the duodenum B3.1a 17B. Root Operation for post-operative hemorrhage with cauterization of a bleeder to stop the bleeding
B3.
18B. Root operation to free a median nerve from entrapment B3. 19B. Approach for tonsillectomy or closed reduction of a dislocated fracture B3.
Page 8 20B. Root Operation for the reduction of a displaced fracture B3. Part C: ICD-10-PCS Code Build Process To be an effective coder, one must first have a solid understanding of the ICD-10-PCS system. Learning to code using the ICD-10-PCS Code Book provides the foundation for applying the principles to the code build process.
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- State the first 3 characters of the PCS code for the Root Operation identified in the Alphabetic Index. The first 3 characters of the PCS code for the root operation Resection identified in the alphabetic index are 0FT.
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- Locate that table in the PCS Code Book Code Tables. Indicate the page number of the Code Table. Page number 713
- Based on the procedure definition, state the body part and the corresponding 4th^ character value for Body Part from the code table. Based on the procedure definition, the body part is the Gallbladder. The corresponding 4th character value for Body Part from the code table is 4 making the complete PCS code 0FT4.
- Research the term for the type of approach stated in the procedural statement. State the definition and your source. The type of approach stated is Percutaneous Endoscopic, the definition of Percutaneous Endoscopic is medical procedure where a feeding tube is entered directly through the abdominal wall via small incision.
- Based on the information from #9, state the Approach and its definition along with the character value for the 5 th character Approach selected from the code table. Based on the information from #9, the Approach is 4, which is Percutaneous Endoscopic, meaning a feeding tube was entered directly through the abdominal via a small incision.
- 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 a device is not to be coded, because a device was not used during the procedure. The 6th character value should be Z(no device).
- Based on the procedural statement, enter the 7 th character value and code character for the Qualifier from the code table. Based on the procedural statement the 7 th^ character value and code character for the qualifier is Z (no qualifier)
- State the final 7-character PCS Code as determined via the PCS Code Book code table
0FT44ZZ
- 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 Body Part Approach Device Qualifier
Page 13 Medical and Surgical (0) Gastrointestin al (D) Excision (B) Cecum (H) Via^ a^ natural orifice endoscopic (8) None (Z) Diagnostic (X)
