Inpatient Facility Coding & Compliance Alert

Key: Boil down what the physician performed to match root operation definitions.

Now that four months have passed since ICD-10 implementation, it’s time for a little introspection. “The implementation of ICD-10 seems to have gone very smoothly,” claims Duane C. Abbey, PhD, president of Abbey and Abbey Consultants, Inc., in Ames, IA. “I have not encountered any situations where healthcare providers are having difficulty. Most of my work is with hospitals and the lack of any feedback is amazing. I would guess that there might be more problems on the physician side with the diagnosis coding.”

Miles to go: So far, so good, but you still need to ensure everyone is solid with their understanding of ICD-10-PCS. For example, how do you handle the coding scenario when your physician performed a procedure amenable to multiple root operations? Read on for details on how to wade through such a situation.

Note: If your physician performs root operations with distinct objectives, you should submit the most suitable and befitting PCS code accordingly. Be aware that your selection can be tricky, because you need to distinguish between similar root operation attributes.

Take a Broad Overview of 3^rd Character

When you build a PCS code, such as from the medical and surgical section, you have to pick root operations as appropriate, arranged into nine categories. You will need to break down what the physician performed precisely into one of 31 root operations in those categories. Your root operations are (in alphabetic order):

Watch out: Some of these root operations are similar. For instance, “resection” has a subtle distinction from “excision.”

An “excision” means the physician used a sharp instrument to cut out or off a portion of body part without replacement. Examples of “excision” procedures are a breast lumpectomy or liver biopsy.

On the other hand, a “resection” means the physician cut out or off, without replacement, all of a body system. Examples of “resection” procedures are a total mastectomy or a cholecystectomy.

The Nine Categories Of Root Operations

• -Root operations that take out some/all of a body part 
• -Root operations that take out solids/fluids/gasses -from a body part 
• -Root operations involving cutting or separation only 
• -Root operations that put in/put back or move some/all of a body part 
• -Root operations that alter the diameter/route of a tubular body part 
• -Root operations that always involve a device 
• -Root operations involving examination only 
• -Root operations that include other repairs
• -Root operations that include other objectives 

Difference: “Excision” refers to the removal of a portion of a body part, whereas “resection” refers to the removal of all of a body system.

Examine This Sample PCS Chart

Suppose your physician performs an insertion of an infusion pump into the patient’s chest. Using a percutaneous approach, he inserts the pump underneath the subcutaneous tissue.

First of all, you know this is part of the Medical and Surgical section of the PCS manual. Then, you should identify the body system. This would be the subcutaneous tissue and fascia. The physician inserted the infusion pump. Because this is an insertion, you would use root operation “H” (meaning insertion) as your third character which implies putting in a nonbiological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part.

Here’s how to code this: Go to the PCS Index > look for Infusion device, pump > see Chest > 0JH6 > locate table 0JH6 and then go across the row to finish building the code. Here is what your chart looks like:

Result: Your final code selection is 0JH63VZ.

Remember: To code smoothly in PCS is easy, if you just try and fix the coding scenario facts and findings neatly into the seven character fields. Next, go to the index with the most significant key word from the report that denotes the procedure performed, and you would never go wrong. “Coding staff will probably be using some sort of computer system to do the coding, but coders must know the underlying logical process,” explains Abbey. “Also, the role of definitions is critical and coding staff must work with physicians to obtain the necessary documentation to sort out the proper terms.”