Inpatient Facility Coding & Compliance Alert

Choose the keywords carefully.

In ICD-10 PCS coding, you must organize each of the seven characters to define one aspect of the procedure performed and give a complete picture. Be careful to choose your fifth character based on the physician approach. Let us show you how.

Definition: “Approach” as represented by the fifth character refers to the technique a physician uses to access the site of the procedure.

Fifth Character: Approaches

0: Open
3: Percutaneous
4: Percutaneous endoscopic
7: Via natural or artificial opening 
8: Via natural or artificial opening endoscopic
F: Via natural or artificial opening with percutaneous endoscopic assistance
X: External

ICD-10-PCS offers the seven options for identifying the approach.

Here is how you should define each one:

Open: The physician cuts through the skin or mucous membrane and any other body layers 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 and visualize 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 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 for the procedure.

External: The physician will perform procedure directly on the skin or mucous membrane or indirectly by application of external force through the skin or mucous membrane.

Examine This Sample PCS Chart

Example 1: Suppose your physician performs liposuction on the patient’s left upper arm. This procedure involves a small tube-like instrument called a cannula which is inserted through tiny incisions to surgically remove fat cells. Therefore the approach is called percutaneous.

As you know, this is a part of the Medical and Surgical section of the PCS manual. Then, you identify the body system as the subcutaneous tissue and fascia. The physician performed liposuction, or removal of fat cells. Because this is an extraction, you would use root operation “D” (meaning extraction) as your third character, which implies pulling or stripping out or off all or a portion of a body part by the use of force.

Here’s how to code this: Go to the PCS Index > look for extraction > see Subcutaneous Tissue and Fascia > Upper Arm > Left >0JDF > locate table 0JDF and then go across the row to finish building the code. Here is what your chart looks like:

Result: Your final code selection is 0JDF3ZZ.

Example 2: Suppose your physician performs a dilation and curettage (D&C). During a D&C, the physician will dilate the cervix by inserting instrumentation via the vagina and remove uterine tissue. Because the approach is via a natural opening, and does not involve any endoscopic or percutaneous endoscopic assistance, you can apply a fifth character of “7.”

This is part of the Medical and Surgical section of the PCS manual, and the body system is the Female Reproductive System. The physician performed dilation and curettage (D&C). Because this is also a sort of an extraction, here too you would use root operation “D” (meaning extraction) as your third character.

Here’s how to code this: Go to the PCS Index > look for extraction > see Endometrium >0UDB > locate table 0UDB and then go across the row to finish building the code. Here is what your chart looks like:

You thus arrive at the code 0UDB7ZZ.

Remember: To code smoothly in PCS is easy, if you just choose the right keywords for searching in the index. In the previous case, for example, a beginning coder may try to look up “dilation, vagina,” which would mislead her to 0U7G. In case she looks up “curettage,” it redirects one to excision or extraction. One can again tread the wrong path if they choose “excision, uterus” as they would land up with 0UB9 and nowhere to go.

Try to fit the coding scenario facts and findings neatly into the seven character fields. And then go to the index with the most significant key word from the report that denotes the procedure performed, and you should never go wrong.

The big picture: “We are now at a stage where enough time has elapsed so that hospitals can now have coding validation audits,” feels Duane C. Abbey, PhD, president of Abbey and Abbey Consultants Inc., in Ames, IA. “Having an outside entity or outside coders review the coding and associated documentation will give a picture as to whether things are being done correctly and/or if additional training is needed.”