ICD-10-PCS Reference Manual

[Pages:245]Preliminary 12/17/08

ICD-10-PCS Reference Manual

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THE INTERNATIONAL CLASSIFICATION OF DISEASES Tenth

Revision Procedure Coding System (ICD-10-PCS) was developed with the support of the Centers for Medicare and Medicaid Services, under contract Nos. 90-1138, 91-22300, 500-95-0005, and HHSM-500-2004-00011C to 3M Health Information Systems.

Rhonda R. Butler, CCS, CCS-P Robert L. Mullin, M.D. Thelma M. Grant, MBA, RHIA Richard F. Averill, M.S. Barbara A. Steinbeck, RHIT The opinions expressed are solely those of the authors, and do not necessarily represent those of the Centers for Medicare and Medicaid Services.

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Preface

THE INTERNATIONAL CLASSIFICATION OF DISEASES Tenth

Revision Procedure Coding System (ICD-10-PCS) is a new sys tem for coding inpatient procedures, developed for the Centers for Medicare and Medicaid Services (CMS).

This manual is written as a general introduction for data manag ers, payers, administrators, and medical record coders. For readers who do not need a detailed understanding of ICD-10-PCS but would like a general introduction, the material in chapter 1 and the appendices is recommended.

Manual organization Chapter 1 Chapter 2

The manual is organized into the following chapters and appen dices. A glossary also provides a list of terms introduced in the manual.

Overview. Includes a general introduction to ICD-10-PCS, a brief history of its development, and a presentation of the code structure, organization, and characteristics. The first part of the overview contains basic information; the second and third parts discuss structure, characteristics, and applications in more detail.

Procedures in the Medical and Surgical section. Provides reference material for each root operation in the MEDICAL AND SURGICAL section (0), with the full definition, additional explana tion as needed, a code example, and coding exercises for each root operation.

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Chapter 3 Chapter 4 Appendix A Appendix B

Procedures in the Medical and Surgical-related sections. Provides reference material for each of the Medical and Surgical-related sections (1?9), with definitions, additional explanation as needed, a code example, and coding exercises for each section.

Procedures in the ancillary sections. Provides reference material for each of the ancillary sections (B?D, F?H), with defi nitions, additional explanation as needed, a code example, and coding exercises for each section.

ICD-10-PCS definitions. Tables listing the full definitions of all root operations and approaches in the MEDICAL AND SURGICAL section.

ICD-10-PCS draft coding guidelines. Contains draft guide lines for coding procedures with ICD-10-PCS.

Conventions used Small capital letters Root operation boxes

This manual uses several conventions throughout, as described below.

Small capital letters are used to distinguish words that define code components, as in the root operation TRANSPLANTATION.

Root operation boxes are used to present the full definition of root operations in the MEDICAL AND SURGICAL section, including explanation and examples. A root operation box is shown below. Root operation boxes are used in chapter 2.

Drainage 9

Definition Explanation Examples

Taking or letting out fluids and/or gases from a body part The fluids or gases may be normal or abnormal Incision and drainage, thoracentesis

Table excerpts

Table excerpts present a single code in the ICD-10-PCS Table format, identifying all components of the code. Text descrip tions are truncated as needed to fit the compressed format, as in the example below.

Character 1 Section

MEDICAL AND SURGICAL

0

Character 2 Body System

Character 3 Root Operation

RESPIRATORY

EXCISION

B

B

Character 4 Body Part

Character 5 Approach

LOWER LOBE BRONCHUS, RT

OPEN

6

0

Character 6 Device

NO DEVICE

Character 7 Qualifier

DIAGNOSTIC

Z

X

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Root operation groups

This table is used only in chapter 2 to organize root operations in the MEDICAL AND SURGICAL section, highlighting distinguish ing features.

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Root operation Procedure Objective

Procedure Site

Drainage

Taking/letting out fluids/gases Within a body part

Extirpation

Taking/cutting out solid matter Within a body part

Fragmentation Breaking solid matter into pieces Within a body part without removal

Example I&D of perinephric cyst Taking out a kidney stone Lithotripsy of kidney stone

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