chapter 8 ICD

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Exercise8.1 without referring to the alphabetic index, underline the word(s)in each item that indicates the main turns foreach procedure 1. Laparoscopic cholecystectomy 2. Resection of pancreas 3. Bilateral oophorectomy 4. Incision and drainage of abscess, neck 5. Bowel resection with transverse colostomy 6. Fusion of L5-S1 7. Lysis of intestinal adhesions Exercise8.2 without referring to ICD10 PCS, identify the order in which the following tables(represented by the first three characters)can be located

1. OJQ5 2. OJ9 4 3. B31 3 4. 09B 1 5. 09W 2 ICD-10-CM/PCS Coding I – Study Guide Chapter 8 – Basic ICD-10-PCS Coding Steps Coding Handbook 2022 Term to know 1. What is a principal procedure? The United States uses the International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) to categorize and code all medical procedures. Prior to the adoption of ICD-10-PCS, procedures were coded using Volume 3 of the ICD-9-CM system, which has since been replaced by this system. All medical procedures carried out in hospitals and other healthcare settings are to be classified and coded using the ICD-10-PCS, which is intended to do so consistently and accurately. The ICD-10-PCS coding guidelines offer detailed guidelines on how to accurately code medical procedures. These recommendations are essential for choosing the main procedure carried out in a specific hospital setting. The most extensive medical procedure carried out during a single episode of care is referred to as the principal procedure. It is crucial to choose the primary procedure correctly because this will be used to calculate how much will be paid for the hospital stay. The intent of the procedure, its complexity, and the amount of resources used during the procedure must all be taken into account when choosing the principal procedure. The procedure's primary goal, as well as any secondary goals that might be required to achieve the goal, are referred to as the procedure's intent. For instance, the removal of the gallbladder is the main goal of a laparoscopic cholecystectomy on a patient. To complete the procedure, additional goals such as concurrent common bile duct repair may be required. The United States uses the International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) to categorize and code

all medical procedures. Prior to the adoption of ICD-10-PCS, procedures were coded using Volume 3 of the ICD-9-CM system, which has since been replaced by this system. All medical procedures carried out in hospitals and other healthcare settings are to be classified and coded using the ICD-10-PCS, which is intended to do so consistently and accurately. The ICD-10-PCS coding guidelines offer detailed guidelines on how to accurately code medical procedures. These recommendations are essential for choosing the main procedure carried out in a specific hospital setting. The most extensive medical procedure carried out during a single episode of care is referred to as the principal procedure. It is crucial to choose the primary procedure correctly because this will be used to calculate how much will be paid for the hospital stay. The intent of the procedure, its complexity, and the amount of resources used during the procedure must all be taken into account when choosing the principal procedure. The procedure's primary goal, as well as any secondary goals that might be required to achieve the goal, are referred to as the procedure's intent. For instance, the removal of the gallbladder is the main goal of a laparoscopic cholecystectomy on a patient. To complete the procedure, additional goals such as concurrent common bile duct repair may be required. When choosing the main procedure, the procedure's complexity must also be taken into account. This includes elements like the anatomical site, the method of the procedure, and the equipment used. The most complicated procedure should be chosen as the main procedure because this will determine how much money will be reimbursed for the hospital stay. Finally, when choosing the main procedure, consideration should be given to the amount of resources used to carry out the procedure. This includes how many people are involved, how long it takes, how much equipment and supplies are used, and any additional resources that might be required to complete the procedure. As the procedure that will determine how much money will be reimbursed for the hospital stay, it is crucial to choose the procedure that requires the most resources as the primary procedure. The precise steps for choosing the principal procedure are laid out in the ICD-10-PCS coding guidelines. These guidelines include figuring out the procedure's purpose, figuring out how difficult it is to execute, and figuring out how many resources are required. By adhering to these rules, coders can choose the most thorough and resource- intensive procedure as the principal procedure, guaranteeing that the hospital will be fairly compensated for the services rendered.

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principal procedure a procedure performed for definitive treatment or necessary to care for a complication guidelines for designating principal procedures 1) if 2 procedures equally meet the definition, the principal procedure is the one most related to the principal diagnosis 2) if 2 procedures are equally related to the principal diagnosis, the most resource-intensive or complex procedure is usually designated as principal procedure 3) follow the UHDDS definition unless a payer has substantially different reporting requirements procedure performed for definitive treatment of both principal and secondary diagnoses sequence the procedure performed for definitive treatment most related to the principal diagnosis as the principal procedure procedure performed for definitive treatment & diagnostic procedures performed for principal & secondary diagnoses sequence the procedure performed for definitive treatment most related to the principal diagnosis as the principal procedure diagnostic procedure is performed for principal diagnosis & a procedure is performed for definitive treatment of a secondary diagnosis sequence the diagnostic procedure as the principal procedure, since the procedure most related to the principal diagnosis takes precedence

when no procedures are performed for principal diagnosis, but definite treatment & diagnostic treatments performed for secondary diagnosis sequence the procedure performed for definitive treatment of the secondary diagnosis as the principal procedure, since no procedures are related to the principal diagnosis Introduction 2. What are the steps in locating codes in ICD-10-PCS? Explain. First, locate the main term in the Alphabetic Index. · Follow any cross-reference instructions. · Obtain the first three or four characters for the procedure. · In a few instances, complete seven-character codes are provided. Second, find the applicable Table. · Review the section, body system, and root operation definition, and verify that the first three characters referenced by the Index are correct. Third, continue building the ICD-10-PCS code by selecting a value from each column for the remaining four characters, as follows: · Select a value from the body part column for the fourth character. · Select a value from the approach column for the fifth character. · Select a value from the device column for the sixth character. · Select a value from the qualifier column for the seventh character.

basic coding steps 1) Locate the main term in the Alphabetic Index 2) Find the applicable Table 3) Continue building the code by selecting a value from each column for the remaining 4 characters locating an entry in the Alphabetic Index -main terms may be a ... 1) common procedure (refers to root operation & body part) 2) root operation (subterms will be body parts) 3) body part (helpful reference to ICD-10-PCS body term) -subterms provide more specific information arrangement of Tables in ICD-10-PCS -begins with section (0,1,2,3,4,5,6,7,8,9,B,C,D,F,G,H) -for character positions 2 thru 7, same convention is used with numeric values first, followed by alphabetic values Basic Coding Steps 1. Locate the main term in the Alphabetic Index -Follow any cross-reference instructions -Obtain the first three or four characters for the procedure -In a few instances, complete seven-character codes are provided

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2. Find the applicable Table -Review the section, body system and root operation definition, and verify that the first three characters reference by the Index are correct. 3. Continue Building the ICD-10-PCS code by selecting a value from each column for the remaining four characters, as follows -Select a value from the body part column for the fourth character -Select a value from the approach column for the fifth character -Select a value from the device column for the sixth character -Select a value from the qualifier column for the seventh character Valid Codes can be built using all combinations of choices in characters 4 through 7 that are in the same row of the Table All ICD-10-PCS codes are seven characters long; the code must specify all seven characters to be valid Locate Entry in Alphabetic Index -The first step in coding is to locate the main term in the Alphabetic Index -The index can be used to access the Tables. -Main terms may be --Common procedure term (appendectomy, chocystectomy) --Root operation value --Body parts -Subterms provide more specific information -Each indention level of the index is represented below by a hyphen -Some publishers have adopted the convention used in the ICD- 10-CM Index of adding a dash (-) at the end of an index entry to indicate that additional characters are required. -When the main term is a root operation value (eg excision) the subterms will be body parts where the operation was performed

-When the main term is a common procedure, references are provided to the corresponding ICD-10-PCS root operation and body part -When the main term is an anatomical term, helpful references are provided to identify specific ICD-10-PCS body parts -It is not necessary to start with the Alphabetic Index before proceeding to the tables to complete a code -A valid code may be chosen directly from the Tables, but looking up the code will require a thorough familiarity with the body systems and root operations. 3. Valid codes can be built using all combinations of choices in characters 4-7 that are in the of the Table. Every valid code must have 7 characters!!! Alphabetic Index -arranged in alphabetical order based on the type of procedure performed -Refers to Tables by specifying the first three or four characters of a code -Index will not specify the complete code -- refer to Tables.Complete codes are only found in tables. -The purpose of the Alphabetic Index is to locate the appropriate table that contains all information necessary to construct a procedure code. -It is not required to consult the Index first before proceeding to the Tables to complete the code. Locate the Main Term in the Alphabetic Index 4. What types of words are main terms? 5. How are indention levels indicated under the main term?

6. When common procedures and anatomical terms are found as main terms, what follows in the Alphabetical Index? 1. Main Terms: § In the Alphabetic Index, a main term is a word that identifies a specific condition or injury. These terms are often associated with documentation in medical records. § When you encounter a word that appears in bold type and begins with a capital letter, it is likely a main term1. 2. Indention Levels: § Under the main term, you’ll find subterms and more specific subterms. These are indented to varying levels. § The standard indention places subterms one level below the main term. Subterms begin with a lowercase letter and are printed in regular type1. 3. Common Procedures and Anatomical Terms: § When common procedures (such as surgeries) or anatomical terms (related to body structures) appear as main terms, what follows in the Alphabetic Index are more specific subterms. § These subterms provide additional details, allowing coders to pinpoint the exact condition or injury1 Exercise 8.1 – see text to complete. Hint: choose the name of the procedure (noun), rather than a descriptor or an adjective Find the Applicable Table The tables are arranged in a series, beginning with section 0, Medical and Surgical, and body system 0, and proceeding in numerical order. 7. How are numbered and alphabetic sections arranged – numeric then alphabetic, alphabetic then numeric, or intermixed?

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1. Numeric Then Alphabetic: § In this arrangement, numeric sections (such as those labeled with numbers) come before alphabetic sections (such as those labeled with letters). § For example, if you have sections numbered 1, 2, 3, followed by sections labeled A, B, C, the order would be: 1, 2, 3, A, B, C. 2. Alphabetic Then Numeric: § In this arrangement, alphabetic sections precede numeric sections. § For instance, if you have sections labeled A, B, C, followed by sections numbered 1, 2, 3, the order would be: A, B, C, 1, 2, 3. 3. Intermixed: § Sometimes, sections are intermixed, especially in complex systems or databases. § For instance, you might encounter a sequence like: 1, A, 2, B, C, 3. Exercise 8.2 – see text to complete Coding Demonstrations – Read and Do Total Laparoscopic Cholecystectomy The term “resection” rather than the term “excision” selected for the root operation because the term Resection indicates the total removal of the body part. The procedure was a total cholecystectomy. 8. Valid codes contain all combinations of choices in characters 4 through 7 contained in the of the Table. 1. All ICD-10-PCS codes contain seven characters, each with a distinct definition. Each character serves as an axis of classification, providing information about the performed procedure. a) The possible values for each character include the numbers 0 through 9 and the letters of the alphabet. These values are assigned to each axis of classification within the seven-character code.

b) Valid values for an axis of classification can be added as needed. c) The meaning of any single value depends on its axis of classification and any preceding values. In other words, the code is constructed by considering how each character depends on the others. d) The alphabetic index helps locate the appropriate table containing all necessary information to construct a procedure code. Always consult the PCS Tables to find the most suitable valid code. e) Within a PCS table, valid codes include all combinations of choices in characters 4 through 7 found in the same row of the table. For example, if we have a code like 0JHT3VZ, it is valid because it adheres to the specified guidelines. However, 0JHW3VZ would not be a valid code. Remember that these guidelines ensure consistency and accuracy in medical coding. If you encounter any uncertainties, querying the physician for necessary information is crucial1234. > Below Knee Amputation, Distal Portion, Right Leg 9. What is the ICD-10-PCS term for “amputation”? Uniform Hospital Discharge Data Set (UHDDS) for Reporting Procedures 10. Which procedures does the UHDDS require to be reported? rules for reporting procedures UHDDS - must report all significant procedures

CMS - must report all procedures affecting payment Hospitals - may report other procedures at their discretion UHDDS significant procedures 1) Is surgical in nature 2) Carries an anesthetic risk 3) Carries a procedural risk 4) Requires specialized training 11. Which procedures are required to be reported by Medicare? The Uniform Hospital Discharge Data Set (UHDDS) is used for reporting inpatient data in acute care, short-term care, and long-term care hospitals. It provides a minimum set of items based on standard definitions to ensure consistent data for multiple users. The UHDDS is required for reporting Medicare and Medicaid patients1. Here are the key procedures that the UHDDS requires to be reported: a. Principal Diagnosis: This refers to the condition established after study to be chiefly responsible for the patient’s admission to the hospital. It is crucial for cost comparisons, care analysis, and utilization review. Additionally, many third-party payers, including Medicare, base reimbursement primarily on the principal diagnosis. b. Other Significant Diagnoses: These are additional diagnoses that have significance for the specific hospital episode. They contribute to understanding the patient’s overall health condition during their stay. c. All Significant Procedures: The UHDDS mandates reporting of all procedures that are clinically evaluated, diagnostically tested for, therapeutically treated, or increase nursing care or the length of stay of the patient2.

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In addition to Medicare, many other health care payers also use most of the UHDDS for their uniform billing system1. Remember that accurate reporting of these items is essential for effective patient care management and reimbursement processes. 12. What is a significant procedure? The following procedures are considered to be surgical! Incision introduction suturing Excision insertion manipulation Destruction endoscopy Amputation repair A significant procedure is defined as one that meets any of the following conditions: List all 4 conditions.. -Is surgical in nature -carries an anesthetic risk -Carries a procedural risk -Requires specialized training 13. What procedures carry a procedural risk? The UHDDS uses the term “specialized training” to include those procedures performed by specialized professionals, qualified technicians, or clinical teams specifically trained to perform certain procedures,

or whose services are directed primarily to carrying them out. This implies training over and above that ordinarily provided in the education of physicians, nurses, or technicians. Meeting Various Reporting Requirements 14. Under HIPAA, which code set is the standard for reporting surgery and procedures for inpatients? ICD-10-PCS a) ICD-10-PCS (Procedures): This code set is used to report procedures performed exclusively in U.S. inpatient hospital health care settings. Providers document procedures or other treatments for diseases, injuries, and impairments, and coders assign codes based on the patients’ medical record documentation. Physicians do not use this code set to report their services, including ambulatory services and inpatient visits1. b) ICD-10-CM (Diagnoses): All health care providers use this code set in U.S. health care settings. Providers document diagnoses in the patients’ medical records, and coders assign codes based on that documentation. The CDC develops and maintains this code set. Use ICD-10-CM diagnosis codes on all inpatient and outpatient health care claims. Medicare Administrative Contractors (MACs) use them to determine benefits and coverage, but not the amount paid for services provided. Inpatient acute care providers report ICD-10-CM diagnosis and ICD-10-PCS procedure codes on claims to assign the appropriate Medicare Severity-Diagnosis Related Group (MS-DRG) codes used for payment calculation1. c) HCPCS (Level II) codes: These codes are used to report products, supplies, and services not included in Level I CPT codes (for example, ambulance services, drugs, devices, and DMEPOS). Providers report HCPCS codes on claims, and MACs use those codes to determine coverage or the amount paid for services provided, minus patient coinsurance and copayments1. In summary, for inpatient reporting, the combination of ICD-10-PCS and ICD-10-CM codes plays a crucial role in accurately documenting and billing for surgical procedures and diagnoses1. >

15. Under HIPAA, which code set is the standard for reporting hospital outpatient procedures and physician reporting? Under the Health Insurance Portability and Accountability Act (HIPAA), the standard code sets for reporting hospital outpatient procedures and physician reporting are as follows: a) ICD-10-CM (Diagnoses): This code set is used for patient diagnoses in both inpatient and outpatient health care settings. Health care providers document diagnoses in patients’ medical records, and coders assign codes based on that documentation. The Centers for Disease Control and Prevention (CDC) develops and maintains this code set. It is essential to use ICD-10-CM diagnosis codes on all health care claims, including both inpatient and outpatient claims. Medicare Administrative Contractors (MACs) use these codes to determine benefits and coverage, but not the actual payment amount for services provided. Inpatient acute care providers also report ICD-10- CM diagnosis codes on claims to assign the appropriate Medicare Severity-Diagnosis Related Group (MS- DRG) codes used for payment calculation1. b) ICD-10-PCS (Procedures): This code set is specifically used for reporting procedures performed only in U.S. inpatient hospital health care settings. Providers document procedures or other treatments for diseases, injuries, and impairments, and coders assign codes based on patients’ medical record documentation. The Centers for Medicare & Medicaid Services (CMS) develops and maintains the ICD-10-PCS code set. Physicians do not use this code set to report their services, including ambulatory services and inpatient visits. Inpatient acute care providers report both ICD-10-CM diagnosis and ICD-10-PCS procedure codes on claims, and MACs use the MS-DRG system to calculate payment1. c) CPT-4 (Current Procedural Terminology): CPT codes are used for coding professional (physician and outpatient) procedures. The CPT code set, maintained by the American Medical Association (AMA), has been named a HIPAA standard. Physicians and other health care providers use CPT codes to report outpatient services and procedures for treating patients’ diseases, injuries, and impairments2. These standardized code sets play a crucial role in ensuring accurate and consistent reporting of health care information, facilitating efficient billing and claims processing, and supporting quality patient care. Designating the Principal Procedure 16. Give the UHDDS definition of a principal procedure. Principal procedure performed for definitive treatment (rather than for diagnostic or exploratory purposes

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Principal Diagnosis- Definition and Importance Definition: The condition established after study to be chiefly responsible for admission of the patient to the hospital. Importance of correct selection: Significant in cost comparisons, in care analysis, and in utilization review. Crucial for reimbursement because many third-party payers (including Medicare) base reimbursement primarily on principal diagnosis. Principal Diagnosis and " After study" The principal diagnosis is NOT the admitting diagnosis, but the diagnosis found after workup or even after surgery that proves to be the reason for admission. The principal diagnosis is ordinarily listed first in the physician's diagnostic statement, but this is not always the case. Always review the entire medical record to determine the condition that should be designated as the principal diagnosis. Selection of Principal Diagnosis The circumstances of inpatient admission always govern the selection of the principal diagnosis. Coding directives in the ICD-10-CM classification take precedence over all other guidelines. Consistent, complete documentation in the medical record is important. Without such documentation, the application of all coding guidelines is a difficult, if not impossible, task.

17. How is the principal procedure designated when two or more procedures appear to meet the UHDDS definition? Guidelines for Selection of Principal Diagnosis- Two or more conditions. In the unusual situation in which two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of the admission and the diagnostic workup and/or therapy provided, either diagnosis may be sequenced first, unless the Alphabetic Index or the Tabular List directs otherwise Two or more conditions- Cont... When treatment is totally or primarily directed toward one condition, or when only one condition would have required inpatient care, that condition should be designated as the principal diagnosis. If another coding guideline (general or disease-specific) provides sequencing direction, that guideline must be followed. 18. How is the principal procedure designated when two procedures are equally related to the principal diagnosis? The principal procedure is the procedure most related to the principal diagnosis If two procedures are equally related to the principal diagnosis, the most resource-intensive or complex procedure is usually designated as principal 19. When more than one procedure is reported, the principal procedure should be identified as that which relates to the: When more than one procedure is reported, the principal procedure should be identified as that which relates to the principal diagnosis.

Selection of Principal Procedure The following instructions should be applied in the selection of principal procedure and clarification on the importance of the relation to the principal diagnosis when more than one procedure is performed: items 1-4 items 1-4 1. Procedure performed for definitive treatment of both principal diagnosis and secondary diagnosis. 2. Procedure performed for definitive treatment and diagnostic procedures performed for both principal diagnosis and secondary diagnosis. 3. A diagnostic procedure was performed for the principal diagnosis and a procedure is performed for definitive treatment of a secondary diagnosis. 4. No procedures performed that are related to principal diagnosis; procedures performed for definitive treatment and diagnostic procedures were performed for secondary diagnosis. 1. Procedure performed for definitive treatment of both principal diagnosis and secondary diagnosis: a. Sequence procedure performed for definitive treatment most related to principal diagnosis as principal procedure. 2. Procedure performed for definitive treatment and diagnostic procedures performed for both principal diagnosis and secondary diagnosis: a. Sequence procedure performed for definitive treatment most related to principal diagnosis as principal procedure. 3. A diagnostic procedure was performed for the principal diagnosis and a procedure is performed for definitive treatment of a secondary diagnosis: a. Sequence diagnostic procedure as principal procedure, since the procedure most related to the principal diagnosis takes precedence.

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4. No procedures performed that are related to principal diagnosis; procedures performed for definitive treatment and diagnostic procedures were performed for secondary diagnosis: a. 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. 20. If a procedure was performed for definitive treatment of both the principal diagnosis and the secondary diagnosis, the principal procedure is: procedure performed for definitive treatment of both principal and secondary diagnoses sequence the procedure performed for definitive treatment most related to the principal diagnosis as the principal procedure procedure performed for definitive treatment & diagnostic procedures performed for principal & secondary diagnoses sequence the procedure performed for definitive treatment most related to the principal diagnosis as the principal procedure diagnostic procedure is performed for principal diagnosis & a procedure is performed for definitive treatment of a secondary diagnosis sequence the diagnostic procedure as the principal procedure, since the procedure most related to the principal diagnosis takes precedence when no procedures are performed for principal diagnosis, but definite treatment & diagnostic treatments performed for secondary diagnosis sequence the procedure performed for definitive treatment of the secondary diagnosis as the principal procedure, since no procedures are related to the principal diagnosis

When a procedure is performed for definitive treatment of both the principal diagnosis and the secondary diagnosis, the principal procedure should be selected based on the following guidelines: 1. Procedure performed for definitive treatment of both principal diagnosis and secondary diagnosis: w Sequence the procedure performed for definitive treatment that is most related to the principal diagnosis as the principal procedure12. 2. Procedure performed for definitive treatment and diagnostic procedures performed for both principal diagnosis and secondary diagnosis: w Again, sequence the procedure performed for definitive treatment that is most related to the principal diagnosis as the principal procedure12. 3. A diagnostic procedure was performed for the principal diagnosis and a procedure is performed for definitive treatment of a secondary diagnosis: • In this case, the diagnostic procedure should be sequenced as the principal procedure, since it is most related to the principal diagnosis12. Remember that selecting the correct principal procedure is crucial for accurate coding and billing. It ensures that the procedure most relevant to the patient’s condition takes precedence in reporting. 21. If a procedure was performed for definitive treatment, and diagnostic procedures were performed for both the principal diagnosis and a secondary diagnosis, the principal procedure is Selection of Principal Procedure The following instructions should be applied in the selection of principal procedure and clarification on the importance of the relation to the principal diagnosis when more than one procedure is performed: items 1-4

items 1-4 1. Procedure performed for definitive treatment of both principal diagnosis and secondary diagnosis. 2. Procedure performed for definitive treatment and diagnostic procedures performed for both principal diagnosis and secondary diagnosis. 3. A diagnostic procedure was performed for the principal diagnosis and a procedure is performed for definitive treatment of a secondary diagnosis. 4. No procedures performed that are related to principal diagnosis; procedures performed for definitive treatment and diagnostic procedures were performed for secondary diagnosis. 1. Procedure performed for definitive treatment of both principal diagnosis and secondary diagnosis: a. Sequence procedure performed for definitive treatment most related to principal diagnosis as principal procedure. 2. Procedure performed for definitive treatment and diagnostic procedures performed for both principal diagnosis and secondary diagnosis: a. Sequence procedure performed for definitive treatment most related to principal diagnosis as principal procedure. 3. A diagnostic procedure was performed for the principal diagnosis and a procedure is performed for definitive treatment of a secondary diagnosis: a. Sequence diagnostic procedure as principal procedure, since the procedure most related to the principal diagnosis takes precedence. 4. No procedures performed that are related to principal diagnosis; procedures performed for definitive treatment and diagnostic procedures were performed for secondary diagnosis: a. 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.

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When multiple procedures are performed, the selection of the principal procedure depends on the relationship to the principal diagnosis and any secondary diagnoses. Here are the guidelines: 1. Procedure performed for definitive treatment of both principal diagnosis and secondary diagnosis: • Sequence the procedure performed for definitive treatment that is most related to the principal diagnosis as the principal procedure. 2. Procedure performed for definitive treatment and diagnostic procedures performed for both principal diagnosis and secondary diagnosis: • Again, sequence the procedure performed for definitive treatment that is most related to the principal diagnosis as the principal procedure. 3. A diagnostic procedure was performed for the principal diagnosis and a procedure is performed for definitive treatment of a secondary diagnosis: • In this case, prioritize the diagnostic procedure for the principal diagnosis as the principal procedure. 4. No procedures performed that are related to principal diagnosis; procedures performed for definitive treatment and diagnostic procedures were performed for secondary diagnosis: • If no procedures are related to the principal diagnosis, select the procedure performed for definitive treatment of a secondary diagnosis as the principal procedure. 22. If a diagnostic procedure was performed for the principal diagnosis, and a procedure was performed for definitive treatment of a secondary diagnosis, the principal procedure is When considering the selection of the principal procedure, there are specific guidelines to follow, especially when more than one procedure is performed. Let’s break it down: a) Procedure performed for definitive treatment of both principal diagnosis and secondary diagnosis:

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® In this case, the procedure most related to the principal diagnosis should be sequenced as the principal procedure1. b) Procedure performed for definitive treatment and diagnostic procedures performed for both principal diagnosis and secondary diagnosis: ® Again, the procedure most related to the principal diagnosis takes precedence and should be sequenced as the principal procedure1. c) A diagnostic procedure was performed for the principal diagnosis and a procedure is performed for definitive treatment of a secondary diagnosis: ® In this scenario, the diagnostic procedure performed for the principal diagnosis is not considered the principal procedure. Instead, the procedure performed for the definitive treatment of the secondary diagnosis should be sequenced as the principal procedure1. d) No procedures performed that are related to the principal diagnosis; procedures performed for definitive treatment and diagnostic procedures were performed for secondary diagnosis: ® If no procedures directly relate to the principal diagnosis, then the procedure performed for definitive treatment (regardless of whether it’s related to the secondary diagnosis) becomes the principal procedure1. Remember, the principal procedure is the one performed for definitive treatment, rather than for diagnostic or exploratory purposes. It’s essential for accurate coding and billing23 23. If no procedures related to the principal diagnosis were performed, but diagnostic and definitive procedures were performed for a secondary diagnosis, the principal procedure is When no procedures are directly related to the principal diagnosis, but diagnostic and definitive procedures are performed for a secondary diagnosis, the principal procedure should be selected as follows: 1. If a procedure is performed for definitive treatment of both the principal diagnosis and the secondary diagnosis, the procedure most related to the principal diagnosis should be sequenced as the principal procedure. 2. If a procedure is performed for definitive treatment and diagnostic procedures are performed for both the principal diagnosis and the secondary diagnosis, again, the procedure most related to the principal diagnosis should be sequenced as the principal procedure.

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3. In cases where a diagnostic procedure is performed for the principal diagnosis and a procedure is performed for definitive treatment of a secondary diagnosis, the procedure related to the secondary diagnosis should be sequenced as the principal procedure. 4. Finally, if no procedures are performed that are directly related to the principal diagnosis, but procedures are performed for definitive treatment and diagnostic purposes related to the secondary diagnosis, the procedure related to the secondary diagnosis should be sequenced as the principal procedure Remember that accurate sequencing of procedures is crucial for proper coding and billing. Always consult the relevant coding guidelines and documentation to ensure accurate reporting. > external approach the approach procedure performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane is 1. external approach or 2. open approach ex: closed reduction fracture open approach the approach procedure performed by cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure is 1. external approach or 2. open approach ex:cholecystectomy percutaneous approach the approach procedure performed that is entry, by puncture or minor incision of instrumentation through the skin or mucous membrane and/or any other body layers necessary to reach the site is 1. percutaneous approach or 2. percutaneous endoscopic approach ex: peritoneal damage

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percutaneous endoscopic approach the approach procedure performed that is entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and/or any other body layers necessary to reach and visualize the site of the procedure is 1. percutaneous approach or percutaneous endoscopic approach ex: laproscopic cholecystectomy via natural or artificial opening endoscopic the approach procedure performed that is entry of instrumentation through a natural or artificial external opening to reach the site of the procedure is 1. via natural or artificial opening 2. via natural or artificial opening endoscopic or 3. via natural artificial opening with percutaneous endoscopic assistance ex: insertion of endotracheal tube via natural or artificial opening endoscopic the approach procedure performed that is entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the approach is 1. via natural or artificial opening 2. via natural or artificial opening endoscopic, or 3. via natural or artificial opening with percutaneous endoscopic assistance ex:gastroscopy via natural or artificial opening with percutaneous endoscopic tissue the approach procedure performed that is the entry of instrumentation through a natura or artificial external opening, and entry, by puncture or minor incision, of instrumentation through the skin or mucous membrad and any other body layers necessary to aid in the performance of the procedure 1. via natural or artificial opening 2. via natural or artificial opening endoscopic, or 3. via natural or artificial opening with percutaneous endoscopic ex: via laproscopic assisted vaginal hysterectomy

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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 Example: A procedure performed on the alveolar process of the mandible is coded to the mandible body part If the prefix "peri" is combined with a body part to identify the site of the procedure, and the site of the procedure is not further specified, then the procedure is coded to the body part named. Example: A procedure site identified as perirenal is coded to the kidney body part. "Peri" guideline only applies when a more specific body part value is not available Example: A "repair of periurethral laceration" where vulvar tissue is torn, is coded to the body part "vulva" because a specific body part exists in ICD-10-PCS for "vulva" When organs are reconfigured to create new organs, future surgeries performed are assigned to the ICD-10-PCS body part value based on the current function of the organ Example: A removal of polyp from neobladder made of small intestine, now functioning as an artificial bladder, is assigned to body part "bladder" rather than "small intestine" If a procedure is performed on a continuous section of a tubular body part, code the body part value corresponding to the furthest anatomical site from the point of entry Example: A procedure performed on a continuous section of artery from the femoral artery to the external iliac artery with the point of entry at the femoral artery is coded to the external iliac body part.

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Where a specific branch of a body part does not have it's own body part value in PCS, the body part is typically coded to the closes proximal branch that has a specific body part value Example: A procedure performed on the mandibular branch of the trigeminal nerve is coded to the trigeminal nerve body part value. In the cardiovascular body systems, if a general body part is available in the correct root operation table, and coding to a proximal branch would require assigning a code in a different body system, the procedure is coded using the general body part value. Example: Occlusion of the bronchial artery is coded to the body part value "upper artery" in the body system "upper arteries" and not to the body part value "thoracic aorta, descending" in the body system "heart and great vessels" Bilateral body part values are available for a limited number of body parts: -If the identical procedure is performed on contralateral body parts, and a bilateral body part value exists for that body part, a single procedure is coded using the bilateral body part value. -If no bilateral body part value exists, each procedure is coded separately using the appropriate body part value. If a procedure is performed on the skin, subcutaneous tissue or fascia overlying a joint, the procedure is coded to the following body part: Shoulder is coded to Upper Arm Elbow is coded to Lower Arm Wrist is coded to Lower Arm Hip is coded to Upper Leg Knee is coded to Lower Leg

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Ankle is coded to Foot If a body system does not contain a separate body part value for fingers, procedures performed on the fingers are coded to the body part value for the hand Example: excision of the finger muscle is coded to one of the hand muscle body part values in the Muscles Body system Find the applicable table -Refer to the appropriate table after locating the first three or more characters in the Alphabetic Index -It is not necessary to follow reference notes if the Index provides the first three or four characters of a code -To find the appropriate table --PDF on CMS website: Click on the hyperlink represented by the character values provided by the Index --icd-10-PCS book: Manually locate the appropriate table ---Tables are arranged in a series, beginning with section 0, Medical and Surgical, and body system 0, Central Nervous, and proceeding in numerical order. --Sections 0-9 are followed by sections B through D, F through H, and X --The same convention is followd within each Table for the second through seventh characters -- numeric values in order first, followed by alphabetic values in order. Coding demonstration: Total Laparoscopic Cholecystectomy Refer to main term Cholecystectomy -Note two references: "See excision, gallbadder [0FB4] and "See resection, Gallbladder [0FT4] -There is no need to find the index entry for the main term "Excision" subterm "gallbladder" or main term "resection" subterm " gallbladder" as they will both still refer to the same Tables

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-If necessary, refer to Appendix A of ICD-10-PCS and review the definitions. Otherwise, follow the Index entries by locating both Tables (0FB) and (0FT) to determine the difference in the definitions of the root operations "Excision" and "Resection" -Review Table 0FB --First character "0" Medical and Surgical Section --Second character "F" the body system "hepatobiliary system and pancreas" --Third character "B" the root operation "Excision" --Excision is defined on the 0FB table as ctting out or off without replacement, a portion of a body part --Because the procedure is total cholecystectomy "Excision" is not the correct root operation. -Review Table 0FT --Third character T the root operation Resection --Resection is defined on the 0FT table as "cutting out or off, without replacement, all of a body part" --Based on this review "excision, gallbladder" is the root operation for a partial cholecystectomy and "Resection gallbladder" is the root operation for a total cholecystectomy, there 0FT is the correct table. -Continue building the remainder of the code by selecting the remaining values among the appropriate characters from the four columns on the Table --First column - body part -- selct 4 for gallbladder. --Second column approach, because this was laparoscopic procedure, select 4 for percutaneous endoscopic --Third column- device- select "z" for device, because no device was used for this procedure. --Fourth column- qualifier- select Z representing no qualifier --The ICD-10-PCS procedure code, then, is 0FT44ZZ --Note that within an ICD-10-PCS Table, valid codes include all combinations of choices in characters 4 through 7 contained in the same row of the Table.

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chapter 8 ICD

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