ICD-10-PCS (Procedure Codes) has been developed as a replacement for Volume 3 of the ICD-9-CM. ICD-10-PCS has a 7 character alpha-numeric code structure that provides a unique code for all substantially different procedures, and allows new procedures to be incorporated as new codes. All procedures currently performed can be specified in ICD-10-PCS.
Because the fetus is not passing from the mother spontaneously, but is rather being pulled out of the genital canal by force, the root operation for this procedure is Extraction. The body part is Products of Conception. Do not choose the body part value for retained or ectopic products of conception as those don’t apply here.
The Obstetrics section is one of the smaller sections in ICD-10-PCS. It contains a single body system value, pregnancy (0), 12 root operation values, and three body part values: Products of Conception (0), Products of Conception, Retained (1), and Products of Conception, Ectopic (2).
Episiotomies are reported with a code from the Medical and Surgical section of ICD-10-PCS because this procedure is performed on the pregnant female (see ICD-10-PCS coding guideline C1). Note that the body system is Anatomical Regions, General.
Code O80 Encounter for full term uncomplicated delivery is assigned as the principal diagnosis for delivery admissions that meet the following criteria (ICD-10-CM Coding Guideline I.C.15.n): 1 Vaginal delivery at full term 2 No accompanying instrumentation (episiotomy is ok) 3 Single, healthy infant 4 No unresolved antepartum complications 5 No complications of labor or delivery 6 No postpartum complications during the delivery admission
Coding of vaginal deliveries requires a minimum of 3 codes; a principal diagnosis code, an outcome of delivery code and a weeks of gestation code. Fortunately, there are guidelines and notes to provide direction in properly assigning these codes.
For delivery admissions, the principal diagnosis is the condition that prompted the admission. If multiple conditions prompted the admission, the condition most related to the delivery is the principal diagnosis (ICD-10-CM Coding Guideline I.C.15.b.4).
The notes at the beginning of Chapter 15 Pregnancy, Childbirth and the Puerperium indicate that in addition to the Chapter 15 codes, the coder should assign a code from category Z3A, Weeks of gestation, to identify the specific week of the pregnancy, if known. The guidelines provide further direction, ...
Categories Z40-Z53 are intended for use to indicate a reason for care. They may be used for patients who have already been treated for a disease or injury, but who are receiving aftercare or prophylactic care, or care to consolidate the treatment, or to deal with a residual state. Type 2 Excludes.
Z53.20 Procedure and treatment not carried out because of patient's decision for unspecified reasons. Z53.21 Procedure and treatment not carried out due to patient leaving prior to being seen by health care provider. Z53.29 Procedure and treatment not carried out because of patient's decision for other reasons.
The Obstetrics section is a good section with which to begin ICD-10-PCS training because of the relatively limited number of root operations and tables. While there are two root operations that apply only to Obstetrics, the other 10 root operations also are used in the Medical and Surgical section. Learning the definitions of those 10 root operations common to both sections and learning how these definitions are applied in the Obstetrics section will help coders understand how they are used and applied in the Medical and Surgical section as well. In the process of learning ICD-10-PCS Obstetrics coding, coders also will become familiar with the format of the tables and will be able to learn how to easily use these tables to construct a code.
Procedures performed on the products of conception are coded to the Obstetrics section . Procedures performed on the pregnant female other than the products of conception are coded to the appropriate root operation in the Medical and Surgical section.
Example: Amniocentesis is coded to the products of conception body part in the Obstetrics section.
There are limited coding guidelines currently available for ICD-10-PCS. In fact, only the Medical and Surgical section and Obstetrics section have any guidelines at all. For the Obstetric section, the available guidelines include a single guideline related to products of conception and a single guideline related to procedures following delivery or abortion. These guidelines are:
Lauri Gray, RHIT, CPC, has worked in the health information management field for 30 years. She began her career as a health records supervisor in a multi-specialty clinic. Following that she worked in the managed care industry as a contracting and coding specialist for a major HMO. Most recently she has worked as a clinical technical editor of coding and reimbursement print and electronic products. She has also taught medical coding at the College of Eastern Utah. Areas of expertise include: ICD-10-CM, ICD-10-PCS, ICD-9-CM diagnosis and procedure coding, physician coding and reimbursement, claims adjudication processes, third-party reimbursement, RBRVS and fee schedule development. She is a member of the American Academy of Professional Coders (AAPC) and the American Health Information Management Association (AHIMA).
6 - Extracorporeal or Systemic Therapies. In extracorporeal therapy, equipment outside the body is used for a therapeutic purpose that does not involve the assistance or performance of a physiological function. Extracorporeal therapy procedure codes have a first character value of “6”.
3 - Administration. Administration section codes represent procedures for putting in or on a therapeutic, prophylactic, protective, diagnostic, nutritional or physiological substance. Administration procedure codes have a first character value of “3”.
Extracorporeal assistance and performance procedure codes have a first character value of “5”. The second character value for body system is physiological systems.
Nuclear medicine section codes represent procedures that introduce radioactive material into the body in order to create an image, to diagnose and treat pathologic conditions, or to assess metabolic functions. The nuclear medicine section does not include the introduction of encapsulated radioactive material for the treatment of cancer. These procedures are included in the radiation oncology section. Nuclear medicine procedure codes have a first character value of “C”. The second character specifies the body system on which the nuclear medicine procedure is performed. The third character root type indicates the type of nuclear medicine procedure (e.g., planar imaging or non-imaging uptake).
Measurement and monitoring procedure codes have a first character value of “4”. The second character value for body system is either physiological systems or physiological devices.
Placement section codes represent procedures for putting an externally placed device in or on a body region for the purpose of protection, immobilization, stretching, compression or packing. Placement procedure codes have a first character value of “2”.
The Medical and Surgical section codes represent the vast majority of procedures reported in an inpatient setting. Medical and surgical procedure codes have a first character value of "0". The 2nd character indicates the general body system (e.g., gastrointestinal). The first through fifth characters are always assigned a specific value, ...