PCS Module 4
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Rasmussen College, Minneapolis *
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Mechanical Engineering
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Jan 9, 2024
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Module 04 ICD-10-PCS Coding
In-Depth Look at How to Code for Inpatient Procedures
The Clintegrity Encoder will be introduced in this module.
2
•
This week it will be important to do your reading assignment from the code book and the information in the course under “Lesson Content”. •
Listen to the Live Classroom session before doing any of the assignments.
•
The reading in the code book is critical in helping you to understand how the code book is structured and the coding guidelines are organized as well as how to apply them to the procedural statements. •
It is not intended for you to memorize all of the information. It is important, however, to become familiar with the guidelines and definitions to be able to find the information when needed to code correctly and code according to guidelines.
Module 04 Reading Assignment
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3
•
ICD-10-PCS coding is very different from ICD-10-CM and CPT coding. With ICD-10-PCS, you are building the individual characters of the code based on coding guidelines, definitions, and in alignment with the provider documentation.
•
All codes have 7 characters.
•
The physician is not expected to use PCS terms. It is the coder’s responsibility to determine how the documentation equates to PCS definitions.
Overview of ICD 10 PCS Coding
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Medical and Surgical Section
Largest section in the ICD-10-
PCS Code Book.
The first character of a code indicates the section.
For the Medical and Surgical Section the character value is “0”. Most ICD-10-PCS procedure codes come from this section
.
Medical and Surgical Related Sections:
Includes breakdown of body systems
9 Other Sections: e.g. Obstetrics, Placement, Measurement & Monitoring etc.
First characters are 1 - 9
Ancillary Sections:
Includes: 7 sections e.g. Imaging, Nuclear Medicine, Radiation Therapy etc.
First characters: B – D, F – H.
New Technology is an “X”.
4
ICD-10-PCS: 3 Main Sections of Code Tables 12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential
12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential
5
Section
0 Medical and Surgical
1 Obstetrics
2 Placement
3 Administration
4 Measurement and Monitoring
5 Extracorporeal or Systemic Assistance and Performance
6 Extracorporeal or Systemic Therapies
7 Osteopathic
8 Other Procedures
9 Chiropractic
B Imaging
C Nuclear Medicine
D Radiation Therapy
F Physical Rehabilitation and Diagnostic Audiology
G Mental Health
H Substance Abuse Treatment
X New Technology
ICD-10 PCS SECTIONS
•
Central Nervous System/Cranial Nerve
•
Peripheral Nervous System
•
Heart and Great Vessels
•
Upper Arteries
•
Lower Arteries
•
Upper Veins
•
Lower Veins
•
Lymphatic and Hemic System
•
Eye
•
Ear, Nose, Sinus
•
Respiratory System
•
Mouth and Throat
•
Gastrointestinal System
•
Hepatobiliary System and Pancreas
•
Endocrine System
•
Skin and Breast
•
Subcutaneous Tissue and Fascia
•
Muscles
•
Tendons
•
Bursae and Ligaments
•
Head and Facial Bones
•
Upper Bones
•
Lower Bones
•
Upper Joints
•
Lower Joints
•
Urinary System
•
Female Reproductive System
•
Male Reproductive System
•
Anatomical Regions General
•
Anatomical Regions Upper Extremities
•
Anatomical Regions Lower Extremities
6
Medical and Surgical Section
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•
Obstetrics
•
Placement
•
Administration
•
Measurement and Monitoring
•
Extracorporeal or Systemic Assistance and Performances
•
Extracorporeal of Systemic Therapies
•
Osteopathic
•
Other Procedures
•
Chiropractic
•
Imaging
•
Nuclear Medicine
•
Radiation Therapy
•
Physical Rehabilitation and Diagnostic Audiology
•
Mental Health
•
Substance Abuse
•
New Technology
•
Appendix A-Root Operation Definitions
•
Appendix B-Type and Qualifier Definitions
•
Appendix C-Approach Definitions
•
Appendix D-Medical and Surgical Body Parts
•
Appendix E- Medical and Surgical Device Table
•
Appendix F-Substance Qualifier Table
•
Appendix G- ONLINE-New ICD-10-PCS Codes; 2020
•
Appendix H-ONLINE-Deleted ICD-10-PCS Codes; 2020
7
Other Sections & Ancillary
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8
Examples
…
•
A1. Seven-character PCS Codes
•
A2. Alphanumeric codes; 0 – 9 and all letters with the exception of O and I
•
A6. Purpose of the Alphabetic Index
•
A7. Intent of Code Tables
•
A8. All seven characters must be specified
•
A9. All combinations of characters must come from the same row in the Code Table
•
A11. The physician is not expected to use PCS terms. It is the coder’s responsibility to determine how the documentation equates to PCS definitions
Coding Conventions
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9
•
There are basic concepts and rules that a coder must understand and apply when assigning ICD-10 PCS codes in order to be ethical, compliant, and accurate for reporting purposes. (Schraffenberger & Palkie, 2020).
•
For ICD-10-PCS there are conventions and guidelines for individual characters of the Medical and Surgical PCS Code Structure. •
Additional guidelines are available for Obstetrics, Radiation Therapy and New Technology.
•
Review the guidelines in the front of the ICD-10-PCS code book.
Official ICD-10-PCS Coding Guidelines
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Medical and Surgical Guidelines address…
•
Body System
•
Root Operation
•
Multiple Procedures
•
Discontinued and Incomplete Procedures
•
Biopsy Procedures
•
Bypass Procedures
•
Fusion Procedures
•
Inspection Procedures
•
Occlusion vs Restriction Procedures
•
Release vs Division Procedures
•
Fracture Procedures
•
Bilateral Body Parts
•
External Approach
•
Device Guidelines
10
Coding Guidelines
Medical and Surgical Guidelines address…
•
Body System
•
Root Operation
•
Multiple Procedures
•
Discontinued and Incomplete Procedures
•
Biopsy Procedures
•
Bypass Procedures
•
Fusion Procedures
•
Inspection Procedures
•
Occlusion vs Restriction Procedures
•
Release vs Division Procedures
•
Fracture Procedures
•
Bilateral Body Parts
•
External Approach
•
Device Guidelines
Obstetric Section Guidelines address…
•
Products of conception
•
Procedures following delivery or abortion
Radiation Therapy Section Guidelines…
•
Radiation Therapy Section
•
Brachytherapy
New Technology Section Guidelines…
•
General guidelines
11
Coding Guidelines
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12
ICD-10 PCS CODE STRUCTURE (MEDICAL/SURGICAL)
1
2
3
4
5
6
7
SECTION
BODY SYSTEM
ROOT OPERATION
BODY PART
APPORACH
DEVICE QUALIFIER
0
S
R
C
0
J
9
SECTION
BODY SYSTEM
ROOT OPERATION
BODY PART
APPROACH DEVICE QUALIFER
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14
Read and follow the specific steps given in Lesson Content.
In general…
1. Read the documentation thoroughly
2. Determine the intent or objective of the procedure
3. Locate the Main Term or Root Operation in the Alphabetic Index of the PCS Code Book
4. Locate the Body Part under the Root Operation in the Alphabetic Index
5. Use the first 3 characters of the code from the Index to locate the Code Table
6. Determine the remaining characters (4
th
– 7
th
) based on the documentation and definitions.
7. Check the code against the documentation
ICD-10-PCS Coding Building Steps
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15
Procedure: Colonoscopy with biopsy of the cecum
Identify the Main Term:
Main Term : Biopsy
Why not Colonoscopy??? CG: B3.11a Inspection of a body part performed in order to achieve the objective of a procedure is not coded separately.
Lookup Main Term in the Alphabetic Index:
Biopsy-
See: Excision with Qualifier Diagnostic
See: Extraction with Qualifier Diagnostic
See: Drainage with Qualifier Diagnostic
Determine the appropriate Root Operation based on documentation, definitions and any corresponding coding guidelines:
Root Operation Definitions-
1.
Excision: cutting off or out without replacement a portion of a body part
2.
Extraction: pulling or stripping out or off a portion of a body part by the use of force
3.
Drainage: Taking or letting out fluids and/or gases from a body part
Reference medical terminology and other resources to further your understanding of the clinical terms used by the providers.
Let’s Practice Determining the Root Operation ICD-10-PCS
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16
Procedure: Reduction of displaced fracture
Identify the Main Term:
Lookup Main Term in the Alphabetic Index: Determine the appropriate Root Operation based on documentation, definitions and coding guidelines:
Root Operation Definition –
CG -
Your Turn to Practice Determining the Root Operation ICD-10-PCS
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17
ANSWERS
Procedure: Reduction of displaced fracture
Identify the Main Term:
Main Term : Reduction
Lookup Main Term in the Alphabetic Index: Reduction – Fracture, see
Reposition
Determine the appropriate Root Operation based on documentation, definitions and coding guidelines:
Root Operation Definition –
Reposition: Moving to its normal location or a more suitable location all or a portion of a body part
.
CG-
B3.15
Reduction of a displaced fracture is coded to the root operation Reposition and the application of a cast or splint in conjunction with the Reposition procedure is not coded separately. Treatment of a non-displaced fracture is coded to the procedure performed.
Your Turn to Practice Determining the Root Operation ICD-10-PCS
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18
•
Live Classroom Assessment Code/Questions –
Your Instructor will provide the required response during the live classroom session
.
• Assignment: Code Principles and Code Build Process
–
Enhance your understanding and application of the coding guidelines and definitions in the code build process. –
Three Part Assignment.
•
Lab Activity: ICD-10-PCS Coding
–
Practice identifying the Main Term/Root Operation –
Build the code using the ICD-10-PCS Code Book Alphabetic Index and Code Tables
•
Quiz: Test Your Knowledge of ICD-10-PCS Concepts
Module 04 Assignments
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Introduction to the Clintegrity Encoder for ICD-10-PCS coding:
An encoder is coding software used to locate codes and is used by a coder. The Clintegrity is a book-based encoder. The coding pathway is very similar to coding directly from a physical code book.
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20
•
The Rasmussen College Clintegrity Encoder is accessed via the website: http://quantim.ahima.org:8080/topaz/main.do
•
The encoder is made available the national AHIMA organization.
•
The User ID is RAS001
(zeroes)
•
The Password will be provided by your instructor. –
The password changes on January 1 and July 1 each year.
•
It is very important that the password is never changed by students. Changing the password will lock out the entire college and prevent anyone…including yourself…from using the encoder.
•
If you experience problems getting in, try the following:
–
Try another browser
–
Enter the website address manually into the browser
–
Turn off pop up blockers
–
Sundays tend to have heavy use which may cause problems. Wait 15 minutes and try again.
–
If problems still occur, contact the AHIMA Help Desk or your instructor-DO NOT contact PSC as they are not familiar with the encoders.
How To Access the Clintegrity Encoder
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21
•
Visit the Encoder Software Resources webpage and study the resources listed below.
–
Encoder Software Resources https://guides.rasmussen.edu/healthsciences/encoderr
esources
•
Instructions for Using the Clintegrity Encoder through Rasmussen
•
Video Demonstration of the Clintegrity Encoder
–
The demo provides a brief walk-through demonstrating how to access and utilize the encoder.
Use the encoder only as instructed in the course.
Clintegrity Encoder Demonstration
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1.
Follow the instructions for the Lab Activity regarding when to use the ICD-10-PCS Code Book for a portion of the assignment and when to utilize the encoder. 2.
Screen shots will be required for that portion of the Lab Activity requiring the encoder.
3.
Instructions for taking “screen shots” is available in the course content
View the Clintegrity Encoder Demonstration and review the accompanying power point for instructions on determining the ICD-10-PCS codes using the encoder application.
22
Using the Clintegrity Encoder this Week
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Submission of the Assessment Responses Indicates you…..
-
Listened
to the recorded lecture or participated in the live classroom session
-
Are accountable for the information contained in the lecture materials
Responses to the Assessment Questions need to come from the information presented in lecture
.
Remember your Assessment Response!
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Any Questions?
For the Live Session,
ask your Instructor any questions now.
For the Recorded Session, ask your Instructor questions via Course Email or General Course Questions.
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Schraffenberger, L. A., & Palkie, B. N. (2020). Basic ICD-10-CM and ICD-10-
PCS Coding. Chicago, IL: AHIMA Press, American Health Information Management Association.
References
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- I want to answer all the questions by handwriting.arrow_forwardLearning Task 2: Changes in momentum happen every time. A fast-moving car when suddenly stopped might have damaging effects not only to the vehicle itself but also to the person riding it. Various devices have been installed in vehicles to ensure the safety of the passengers. Can you think of some safety devices installed on vehicles (public/private)? Name at least five (5) of them.arrow_forwardLearning Goal: To describe the shape and behavior of cables that are subjected to concentrated and distributed loads. Part A Structures often use flexible cables to support members and to transmit loads between structural members. Because a cable's weight is often significantly smaller than the load it supports, a cable's weight is considered negligible and, therefore, not used in the analysis. In this tutorial, cables are assumed to be perfectly flexible and inextensible. Thus, once the load is applied the geometry of the cable remains fixed and the cable segment can be treated as a rigid body. Cables of negligible weight support the loading shown. (Figure 1) If W, = 85.0 N , W, = 510 N, YB = 1.40 m, yc = 2.80 m, yp = 0.700 m, and zc = 0.850 m, find zg. Express your answer numerically in meters to three significant figures. > View Available Hint(s) VO AEoI vec IB = 2.048 m Submit Previous Answers X Incorrect; Try Again; 4 attempts remaining Part B Complete previous part(s) W2 O…arrow_forward
- Put together a short presentation (pitch) for a mechanical engineering student, emphasizing his period of the course (10th) and his most significant achievements such as his change from the naval to mechanical course, the learning of programming languages focused on data analysis (Python and SQL), since the engineering course does not explore these skills, and the improvement of Excel with the VBA language.arrow_forwardI need answers to problems 7, 8, and 9. NOTE: Please stop wasting my time and yours by rejecting my question because it DOES NOT REQUIRE YOU TO DRAW anything at all. They are simple questions pertaining to the print provided. READ THE INSTRUCTIONS of the assignment before you just reject it for a FALSE reason or leave it for someone to answer that actually wants to do their job. Thanks.arrow_forwardPlease give me the answers for this i been looking at this for a hour and my head hurtsarrow_forward
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