The following crosswalk between ICD-10-PCS to ICD-9-PCS is based based on the General Equivalence Mappings (GEMS) information:
The ICD-10 Procedure Coding System (ICD-10-PCS) is a catalog of procedural codes used by medical professionals for hospital inpatient healthcare settings. The Centers for Medicare and Medicaid Services (CMS) maintain the catalog in the U.S. releasing yearly updates.
Right sided craniotomy for evacuation of subacute subdural hematoma
OGCR D1: The Section X codes are standalone codes that fully represent the specific procedure described in the code title and do not require any additional codes from other sections of ICD-10-PCS.
Hysteroscopy is the Approach, Via Natural or Artificial Opening Endoscopic (8), and there was No Device (Z). The procedure is documented as Diagnostic, so the Qualifier is "X."
The physician documents an evacuation of a hematoma by incision from the right breast, post-excisional biopsy. Even though the term “evacuation” is not a root operation, it can be found in the alphabetical index as a main term. The sub-term “Hematoma” is listed under Evacuation followed by “ see Extirpation.”.
As most of us have learned by now, the root-operation character in ICD-10-PCS defines the objective of the procedure. There are 31 root operations in the Medical and Surgical Section of ICD-10-PCS, and two of these are discussed below.
The letters OHCT following the last entry of the index indicate that the coder must find the appropriate PCS table labeled 0HC and the fourth character of T. (Note that only a portion of the actual table is provided below.)
Drainage is the process of taking out, or letting out, fluids and/or gases from a body part. This root operation is coded for both diagnostic and therapeutic drainage procedures. Examples of this type of procedure include 1) thoracentesis and 2) the incision and drainage of an abdominal wall abscess.
Since we are still working with a draft copy of ICD-10-CM/PCS, time remains for CMS to consider resolving these types of issues before the final version goes into effect on October 1, 2014.
The PCS guidelines (A11) also state that physicians are not required to use the same terminology as is found in the PCS code descriptions. It is the coder’s responsibility to determine what the medical record documentation means in relation to the PCS definitions.
As with ICD-9-CM guidelines, the same four cooperating parties approve the guidelines for ICD-10-PCS: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), the Centers for Medicare & Medicaid Services (CMS), and the National Center for Health Statistics (NCHS).