Beginning The Journey. ICD-9-CM ICD-10-PCS 2 ICD-9-CM has 3-4 characters All characters are numeric All codes have at least 3 characters ICD-10-PCS

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Text of Beginning The Journey. ICD-9-CM ICD-10-PCS 2 ICD-9-CM has 3-4 characters All characters are...

  • Beginning The Journey

  • ICD-9-CMICD-10-PCS*ICD-9-CM has 3-4 charactersAll characters are numericAll codes have at least 3 charactersICD-10-PCS has 7 charactersEach can be either alpha or numericNumbers 0-9; letters A-H, J-N, P-ZAlpha characters are not case-sensitiveEach code must have 7 charactersICD-10AHIMA

  • ICD-9-CMICD-10-PCS*.XXXX1243XXXXXXX3E04F8010HZ0730DBX58ZICD-10-PCS - StructureICD-10AHIMA

  • * THE OBJECTIVE

    OR

    ACTION OF THE PROCEDURE

  • *There is a specific definition for each one of these rootsICD-10-PCS uses terminology that coders are not accustomed to seeing on a chartThe purpose of this training is to help the coder smoothly transition to the new root operation and their meanings

  • *

    AlterationDivisionInspectionRepositionBypassDrainageMapResectionChangeExcisionOcclusionRestrictionControlExtirpationReattachmentRevisionCreationExtractionReleaseSupplementDestructionFragmentationRemovalTransferDetachmentFusionRepairTransplantationDilationInsertionReplacement

  • 123 4567Body SystemSectionRoot Operation

    Body Part

    ApproachDeviceQualifier*ICD-10AHIMA

  • *0 - Medical and Surgical1 Obstetrics2 Placement3 - Administration4 Measurement and Monitoring5 Extracorporeal Assistance and Performance6 Extracorporeal Therapies7 Osteopathic8 Other Procedures9 ChiropracticB ImagingC Nuclear MedicineD Radiation OncologyF Physical Rehabilitation and Diagnostic AudiologyG Mental HealthH Substance Abuse Treatment

  • *Largest of the 16 sectionsSame definition or meaning Section BD and F-H comprise the Ancillary section of ICD-10-PCS

  • General physiological system or anatomical region involved

    Body SystemValue

    Central Nervous0

    Peripheral Nervous1Heart and Great Vessels2

  • Objective of the procedure31 Root Operations

    Examples of Root OperationsBypassResectionExcisionRemoval

  • Defines the body part or specific anatomical site where the procedure was performedThis is different from character 2 which provides the general Body SystemThere are 34 possible body part values in each body system

    Examples of Body Parts are:LiverKidneyAscending ColonOptic Nerve

  • Defines the approach, or the technique used to reach the procedure siteThere are seven different approach values in the Medical and Surgical section

    Through Skin or mucous membraneThrough an orificeExternalOpenNatural or Artificial OpeningPercutaneousNatural or Artificial Opening EndoscopicPercutaneous EndoscopicNatural or Artificial Opening with Percutaneous Endoscopic Assistance

  • Identified devices that remain after the procedure is completedRemember that all codes require seven charactersThe default value to indicate that NO device was involved is Z

    Examples of Device ValuesDrainage DeviceRadioactive ElementExtraluminal deviceIntraluminal deviceAutologous tissue substituteSynthetic substitute

  • Qualifier for the code that provides additional information about a specific attribute of the procedureThese qualifiers may have a narrow application, to a specific root operation, body system or body partMost procedures will not have an applicable qualifier. The default value for NO qualifier is a Z

    Examples of QualifiersType of TransplantSecond site for a bypassDiagnostic excision (biopsy)

  • *

    0LB50ZZ Excision of right lower arm and wrist tendon, open 0 = Section Medical and Surgical L = Body Section - Tendons B = Root Operation- Excision 5 = Body Part Lower arm and wrist tendon, right 0 = Approach - Open Z = Device No Device Z = Qualifier No Qualifier

  • *It is the coders responsibility to determine which root operation the documentation in the medical record equates to in the PCS definitions

  • *The physician is not expected to use the root terms provided in PCS code description Nor Is the coder required to query the physicians when the correlation between the documentation and the defined PCS term is clear.

  • *

    Billroth I procedure equates to anastomosis

  • *

    The letters O and I are not used in ICD 10 PCS to avoid confusion with the numbers 0 and 1.*All procedure codes in ICD 10 PCS will have 7 characters. There are no decimal points. The PCS code is alpha numeric.*There are 16 sections in ICD 10 PCS which is the first character of the code.*Physicians will continue to use the same terminology they have always used in describing an operative procedure. For example, the surgeon will document a thrombectomy and not an extirpation. That is why it is important to learn and understand the 31 root operations.**