Module 04 Assignment Worksheet

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Mechanical_engineering

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May 2, 2024

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Module 04 Assignment - ICD-10-PCS Coding Principles and Code Build Process Overview: There are 3 parts to this assignment. Each part of the assignment addresses a specific aspect of ICD-10-PCS coding. To code accurately using the ICS-10-PCS system requires the ability to understand and apply the coding principles to clinical documentation by following the designated code build process. Part A: ICD-10-PCS Identify Coding Guidelines The ICD-10-PCS system includes specific conventions and coding guidelines or “rules” which provide instruction on how to accurately construct the codes. This portion of the assignment will provide an opportunity to become more familiar with the guidelines to be used in the determination of the appropriate PCS code. Instructions: Utilize the ICD-10-PCS Official Coding Guidelines presented in the front of the ICD-10-PCS Code Book to match the narrative in the assignment for Part A. Steps: For each coding guideline narrative, 1. Read the narrative in Column 1-Part A in the table below. 2. Match the coding guideline(s) narratives in Column 1-Part A with the Official Coding Guidelines found in the front of the ICD-10-PCS Code Book. 3. Enter the alphanumeric label identifier from the Official Coding Conventions/Guideline(s) in Column 2-Part A of the table in correlation to the coding guideline narrative in Column 1-Part A. If there is more than one applicable Coding Convention or Guideline for the narrative, enter both guideline labels in Column 2-Part A corresponding to the narrative in Column 1-Part A. 4. Reference both A and B conventions and guidelines from The Official Coding Guidelines in the front of the ICD-10-PCS Code Book. Table for Part A - Identify the Official Coding Guideline Column 1-Part A Column 2-Part A ICD-10-PCS Coding Guidelines Coding Guideline Identifiers Example: ICD-10-PCS codes are always composed of 7 characters. A1 1A. It is not required that the provider document using the exact PCS terms. The coder has the responsibility to correlate the clinical documentation stated by the provider to the correct Root Operation definition without querying the provider for clarification. A11 Page 1 of 6

2A. The Code Tables in the code book may be accessed directly or the Alphabetic Index may be used to locate the correct table. It is optional to use the Alphabetic Index, but the PCS Code Tables must always be consulted to determine a valid code. A6 3A. Each of the 7 characters of a PCS codes has a specific “value”. The character can be represented by a number value of 0 – 9 or an alphabetic letter value with the exception of alpha characters O and I to avoid confusion with 0 (zero) and 1 (one). Use of and O or I in a PCS code results in an invalid code. A2 4A. For a PCS code to be valid, the combinations of the 4 th – 7 th character values must all be obtained from the same row in the PCS Code Tables. A9 5A. Components of a procedure that are stated in the Root Operation definition and explanation are NOT coded separately. Also, any procedural steps necessary to reach the operative site and close the operative site, including anastomosis of a tubular body part, are NOT coded separately. B3.1b 6A. Multiple procedures are coded if during the same operative encounter, the same root operation is performed on different body parts as defined by distinct values of the body part character. B3.2 7A. If a procedure is performed on a portion of a body part that does not have a separate body part value, code the body part value corresponding to the whole-body part. B4.1a 8A. The Root Operations Excision, Extraction and Drainage are used for Biopsy procedures along with the Qualifier X-Diagnostic. The X Qualifier is only used for procedures such as biopsies, where the intent of the procedure is to remove a portion of the body part for the purpose of analysis. Documentation that merely states the specimen was sent to Pathology does NOT equate to a diagnostic intent as this is a standard procedure for all removed tissue. B3.4a 9A. Bilateral Body Part values are available for a limited number of body parts. If the identical procedure is performed on contralateral body parts and a bilateral body part value is available in the PCS system, a single procedure is coded using the bilateral body part procedure. If no bilateral body part value exists, each procedure is coded separately using the appropriate body part value for each site. B4.3 10A. When the intended Root Operation is attempted using one Approach, but is converted to a different Approach, multiple procedures are coded. B3.2d 11A. Bypass procedures (non-coronary) are coded by identifying the body part bypassed “from” (specify in the 4 th Character Body Part Value) and the body part bypassed “to” (specify in the 7 th Character Qualifier Value). Coronary artery bypass procedures are coded differently than other bypass procedures. The Body Part identifies the number of coronary arteries bypass to and the Qualifier specifies the vessel bypassed from. B3.6a 12A. Root Operations Excision, Extraction, Repair or Inspection performed on overlapping layers of the musculoskeletal system are coded to the Body Part specifying the deepest layer. B3.5 13A. Inspection of a body part(s) performed to accomplish the intent or objective of the procedure is not coded separately. B3.11a Page 2 of 6

14A. If multiple tubular body parts are inspected, the most distal body part (furthest from the starting point of the inspection) is coded. B3.11b 15A. Procedures performed within an orifice on structures that are visible without the aid of any instrumentation are coded to the Approach External. Procedures performed indirectly by the application of external force through and intervening body layers are coded to the Approach External. B3.5a 16A. A device is coded only if the device remains after the procedure is completed. Materials such as sutures, ligatures, radiological markers and temporary post-operative wound drains are considered integral to the procedure and are not coded as devices. B6.1a 17A. If a procedure is performed on the skin, subcutaneous tissue or fascia overlying a joint, the procedure is coded to a specific body part. B4.6 18A. The Root Operation Control is defined as “Stopping or attempting to stop post-procedural or other acute bleeding.” If an attempt to stop the bleeding is initially unsuccessful and to stop the bleeding requires a more definitive root operation such as Bypass, Detachment, Excision, Extraction, Reposition, Replacement or Resection, then the more definitive root operation is coded instead of Control. B3.7 19A. Reduction of a displaced fracture is coded to the Root Operation Reposition. The application of a cast or splint in conjunction with a Reposition procedure is not coded separately. Treatment of a non-displaced fracture is coded to the procedure performed. B3.15 20A. In the Root Operation Release, the body part value to be coded is the body part being freed and not the tissue being manipulated or cut to free the body part that is entrapped. B3.13 Part B: ICD-10-PCS Apply Coding Guidelines to Clinical Documentation To accurately assign codes in the ICD-10-PCS coding system, the Official Coding Guidelines need to be applied to the clinical documentation as stated in operative notes. The second part of the assignment requires interpretation of the clinical documentation and application of the coding guideline(s) in order to guide the coder in determining the appropriate PCS code. Instructions: In this portion of the assignment, Column 1-Part B provides scenarios that are to be aligned with the appropriate coding guidelines from the Official Coding Guidelines. Steps: 1. Read the narrative scenario in Column 1-Part B in the table below. 2. Identify the appropriate coding guideline(s) for each scenario and enter the alphanumeric label identifier(s) for the Official Coding Guideline in Column 2-Part B. Page 3 of 6

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