Understanding ICD-10-PCS Procedure Coding System
The ICD-10-PCS is a set of codes used to identify services and treatments for inpatient procedures. It features a 7-character coding structure, with each character representing a specific detail. The system is designed to collect data, support electronic health records, and determine payment for medical services. The ICD-10-PCS manual is divided into 16 sections, each containing subsections for various types of procedures. Additionally, the process of creating an ICD-10-PCS code involves identifying the main term in the Alpha Index and selecting appropriate codes for body parts, operations, and more.
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ICD-10-PCS Training Leah Walsh MCCG135 Procedural Coding
ICD-10-PCS * International Classification of Diseases 10th revision of Procedure Coding System What is PCS coding and What is the purpose of PCS coding? The ICD-10-PCS code set to identify services and treatments performed to all inpatient services and procedures. This system allows each code to have a specific structure, to be descriptive, and to expand of the future needs of medical professionals. Most Importantly: This procedure coding system is used to gather data, collect information, determine payment, and support EHR s for all inpatient services and procedures performed. These codes can be built from the index, tables, and appendices given in the ICD-10-PCS manual. ( universalclass.com Davis,2011 )
7-Character Codes: ALL codes are 7-characters in length. Each character will be identified for a specific meaning. Each code will be built from the Tabular Grid. CHARACTER PLACEMENT MEANING 1 .Section of the book 2 .....Body System 3 .Root Operation 4 .....Body Part/Anatomical Site 5 .....Approach 6 ..Device 7 ..Qualifier (Barta, DeVault, & Zeisset, 2011)
The 16 Sections of the ICD-10-PCS Manual ICD-10-PCS Manual is broken up into 16 sections: 0-9, B-D, F-H (Barta, DeVault, & Zeisset, 2011) 16 Sections are further broken into 3 Subsections: -Medical & Surgical -Medical & Surgical Related -Ancillary Each subsection is further broken into 9 components or section values. (0-9) Each Ancillary Section has 6 components. (B-D, F-H) New Technology Section X,Z The subsections below are the Medical & Surgical Related Sections: 1. Obstetrics 2. Placement 3. Administration 4. Measurement & Monitoring 5. Extracorporeal Assistance & Performance 6. Extracorporeal Therapies 7. Osteopathic 8. Other Procedures 9. Chiropractic Ancillary Section: B......Imaging C .Nuclear Medicine D .Radiation Medicine F ..Physical Rehabilitation and Diagnostic Audiology G .Mental Health H .Substance Abuse Treatment New Technology Section: X .New Technology Z .No Qualifier
Steps to create a ICD-10-PCS code: Step 1 clavicle. Excision: head of the femur fits in. system Adductor hallucis muscle: inverted by the plantar nerve and moves the big toe. -use muscle, foot, left -use muscle, foot, right (Leon-Chisen, 2011) Claviculectomy: Surgical removal of all or part of the --see excision, upper bones --see resection, upper bones -Locate the main term in the Alpha Index. -Appendectomy -Acetabulum: socket that the hipbone that the -Cholecystectomy -Left -Right -Adenoids- helps clear infection, part of the lymph -Main term can also be a root operation value -excision -resection -Can be body parts -arm -leg
Step 2 and Step 3 of ICD-10-PCS Coding *Step 1 was beginning in the Alpha Index to find the main term the coder was going to start with. Using the example from ICD-10-PCS Worktext 2020: Steps to code: If a patient is undergoing an open extraction of the bursa in the right elbow. -Look in the index under extraction you will find: Bursae and Ligaments ICD-10-PCS CODE: OMD30ZZ Character Position Meaning Selection 1. Section Medical &Surgical---0 2. Body System Bursae & Ligaments---M 3. Root Operations---Extraction---D 4. Body Part---elbow bursa and ligaments, RIGHT---3 5. The Approach---Open procedure---0 6. Device---Tabular will verify Z 7. Qualifier---Tabular will verify---Z (Leon-Chisen, 2011)
Key Words to Remember: 1. Section of Book: Identifies the general type of procedure 2. Body System: General body system where the procedure was performed 3. Root Operations: Identifies the objective of the procedure 4. Body Part: Indicates the specific anatomical site of the body system on which the procedure was performed 5. Approach: Technique used to reach the site of the procedure 6. Device: Used to specify devices that remain after the procedure is completed 7. Qualifier: Contains unique values for individual procedures. 8. Tables Section: part of the ICD-10-PCS codebook, organized in numerical and alphabetic order by the first character of the code 9. Character-one part of a code that identifies something specific related to the procedure performed 10.Placeholder-Character in a code that is not valid to the procedure Exisit to allow room for future growth of the code system Z is used as a non-applicable.
Reference Page: Davis, (2011). What is ICD-10-PCS? Universal Class. Retrieved from https://www.universalclass.com/articles/medicine/medical- coding/what-is-icd-10-pcs.htm (Barta, DeVault, & Zeisset, 2011). History of ICD-10-PCS. Universal Class. Retrieved from https://www.universalclass.com/articles/medicine/medical- coding/what-is-icd-10-pcs.htm (Leon-Chisen, 2011). Basic ICD-10-PCS Coding Steps. Universal Class. Retrieved from https://www.universalclass.com/articles/medicine/medical- coding/what-is-icd-10-pcs.htm Bowie, M. (2020). Understanding ICD-10-CM & ICD-10-PCS, A Worktext
