Inpatient Facility Coding & Compliance Alert

Tip: Focus on the physician's approach to make the right selection.

As hospital staff and coders prepare for ICD-10-PCS implementation in October 2014, learning what each character of a PCS code represents can be tricky. This is especially true for character 5 if coders don't fully understand the difference between surgical approaches. Read on for the latest on ICD-10-PCS options and how to select the best approach for each case.

Sift Through 7 Possible Approaches

The term "approach" refers to the technique a physician uses to reach the site of the procedure. ICD-10-PCS groups approaches into seven categories:

Each category also has a specific definition to help coders and providers accurately classify procedures. Learn the differences well, because only minor differences separate some from the others.

• Open: The physician cuts through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure.
• Percutaneous: The physician gains entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure.
• Percutaneous endoscopic: The physician gains entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure.
• Via natural or artificial opening: The physician will use a natural or artificial opening to access the site of the procedure.
• Via natural or artificial opening endoscopic: Instrumentation enters through a natural or artificial external opening to reach and visualize the site of the procedure.
• Via natural or artificial opening with percutaneous endoscopic assistance: Like above, this involves instrumentation entering through a natural or artificial external opening, but it also involves puncture or minor incisions through the skin or mucous membrane and any other body layers necessary to aid in the performance of the procedure.
• External: The physician will perform a procedure directly on the skin or mucous membrane or indirectly by application of external force through the skin or mucous membrane.

Practice Choosing the Approach

Each procedural code in ICD-10-PCS has seven alphanumeric characters. Each character defines one aspect of the procedure performed to paint a complete picture:

• Character 1: Medical or surgical
• Character 2: Body system
• Character 3: Root operation
• Character 4: Body part
• Character 5: Approach
• Character 6: Device
• Character 7: Qualifier.

With that knowledge in mind, consider how you would select the correct digit for Character 5 in some real-life examples.

Example 1: Suppose the physician performs liposuction on the patient's left upper arm. This procedure involves a small tube-like instrument called a cannula that is inserted through tiny incisions to surgically remove fat cells. Therefore, the approach is percutaneous. You should use a fifth character of "3."

Coding: In this case, you would report 0JDF3ZZ.The fifth character is "3" because the surgeon used a percutaneous approach.

Example 2: A physician performs a dilation and curettage (D&C). During a D&C, the physician dilates the cervix by inserting instrumentation via the vagina. The instrumentation is then used to remove uterine tissue. Because the approach is via a natural opening (the vagina) and does not involve any endoscopic or percutaneous endoscopic assistance, you will apply a fifth character of "7."

Coding: The full ICD-10-PCS code for this scenario is 0UDB7ZZ. "7" goes in the fifth character spot since the physician approached the procedure through the patient's vagina -- a natural opening. Note that if the physician had used an endoscopic approach through a natural opening, the correct fifth character would be "8" instead.

Editor's note: Keep current on ICD-10-PCS in future issues of Facility Coding and Compliance Alert.