Week 1 PCS CODING

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Rasmussen College, Saint Cloud *

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1126C

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Mechanical Engineering

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Feb 20, 2024

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Week 1 PCS CODING M132/HIM1126C Section 03 ICD-PCS Coding (5.5 Weeks) - Online Plus - 2024 Winter Quarter Term 1 Module 1 ICD-10-PCS Codes Module 1 ICD-10-PCS Codes  ICD-10-PCS Codes The International Classification of Diseases 10th Revision Procedure Coding System (ICD-10- PCS) is used to code inpatient procedures as of October 1, 2015. The development of ICD-10- PCS was funded by the U.S. Centers for Medicare and Medicaid Services (CMS). It is now nationally and internationally used by hospitals for inpatient procedural coding. ICD-10-PCS has a multi-axial, seven-character alphanumeric code structure that provides a unique code for each different procedure and allows new procedures to be easily incorporated as new codes. PCS is unique in that the code is built instead of being provided as a complete code. ICD-10-PCS Coding System In ICD-10-PCS, the coder looks up the main term in the alphabetic index. There the coder may be given the first three or four characters of the code instead of the entire code, or an entire seven-character code may be listed. The coder looks at the appropriate table in the tabular section of the codebook to either verify the seven digits are correct for the procedure or build the complete code from the table directed to in the index. Each coding table has four columns from which the coder will choose the last four characters of the code and add those to the first three or four characters found in the Alphabetic Index .

The main terms are typically based on the root operation or the objective of the procedure. There are names of procedures in the index, but those often refer to the root operation . Root operations are discussed in the course textbook and the appendixes in the back of the codebook. Seven Characters of PCS Codes Let's review the structure of the PCS coding system and make sure the values (meanings) of the characters are clear. Remember, there are seven characters in each code, and each character describes a specific aspect of the procedure. The characters are alphanumeric. 1st Character Identifies the section of the codebook in which the procedure is listed. See your codebook for the current number of sections. 2nd Character Identifies the body system upon which the procedure occurs. There are 31 body systems. 3rd Character Identifies the root operation term, which describes the intent of the operation performed. There are 31 root operations.

4th Character Identifies the specific body part on which the procedure was performed. 5th Character Identifies the approach used in the procedure. This is the technique or the methodology, such as laparoscopic or endoscopic. Different sections of the codebook may use the fifth character to convey information that is different than what is found in the Medical/Surgical section codes. You will need to determine the appropriate code by the information given in the codebook for each section. 6th Character Identifies the device used in the procedure. This identifies any item that remains in the body after the procedure is complete. An example is a pacemaker. If no device is used, the letter "Z" is written to represent "none" or "not applicable." This character can change as to the value if you are in a section other than Medical/Surgical). A device is not what is used to perform the procedure. 7th Character Identifies whatever additional information needs to be conveyed that is not found in the first six characters. It also allows for future expansion of information as medical science advances. If there is no further information that needs to be conveyed, "Z" is written again to indicate "no more information needed." This character can change if you are in a different section than Medical/Surgical.

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Module 1 Determining Root Operation  Understanding how to determine the root operation of a procedure is key to accurate coding in PCS. Knowing root operation will find procedures in the alphabetic index and make finding and building a PCS code much easier. Read the meaning of a root operation in the front of the codebook and Appendix A. Review the descriptions of root operations found in your textbook. To accurately find the correct root operation, the objective or the procedure needs to be determined. Why is this procedure being performed? What is the purpose? It is helpful to think of what benefits the procedure has for the patient. For example, a thoracentesis is performed to drain fluid from the chest cavity. The root operation for thoracentesis is drainage. Match the objective from the documentation to the proper root operation definition. The terminology in the documentation does not need to be an exact match to the PCS definition. Remember, the first three characters in each section have the same meaning. The last four character meanings may be different for each section. Read the tables carefully when building codes. PCS Code Building Instructions Read the medical documentation and determine the main term for the procedure(s) or the root operation and body part that needs coding. Once you have determined the main term or root operation for the procedure, begin building the code. Go to the alphabetic index, and per the documentation, locate the procedure, main term, or root operation and find the first three characters of your code. The code may also go directly to the appropriate table if the body system and root operation are determined. Use the template below as a guide to finding the first three characters of your ICD-10-PCS code: 1. Section ___________________ 2. Body System _________________ 3. Root Operation _______________ Go to the tabular (tables) section of the codebook.

On the edge of the page in the colored band, the first three characters are listed in alphabetic and numeric order. Match the characters to the correct page and then match it to the correct table using the documentation to choose from the four columns of the coding table. Use the documentation to choose the following characters to complete code building using only one letter or number per column of the coding table: 4. Body Part ________________________ 5. Approach _________________________ 6. Device ____________________________ 7. Qualifier ____________________________ Once you have entered the proper number of letters for each of the seven characters based on the medical documentation, the codebook, and textbook information, the code is complete. Example: Documentation: A laryngography was done for the repair of the larynx by laparoscopy. The index entry under Laryngorrhaphy is see Repair, Larynx 0CQS 8. Section is Medical Surgical: 0 9. Body System is mouth and throat: C 10.Root Operation is repair: Q The first three characters are 0CQ Now locate the table found under 0CQ. Locate this in the colored band at the edge of the pages in the Medical Surgical section, where the first three categories are given in alphabetical order. Based on the documentation, pick the

next four codes using the directions in the course, the codebook, and the textbook for building the last four characters of your PCS code. 11.Body Part is Larynx: S 12.Approach is laparoscopic through a natural orifice. Natural opening endoscopic: 8 13.Device value is Z because no device was left in after the procedure. 14.Qualifier value is Z because there is no further information to convey. The code is 0CQS8ZZ. Each of these characters now conveys the information in the documentation for a correct and complete code.

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