Building your ICD-10-PCS expertise with the Optum PCS Code Builder Denise Smith, RN, BSN, CPC efacility Product Manager
AGENDA: Purpose of ICD-10-CM / ICD-10-PCS ICD-10-PCS format Coding conventions Index & tables Range page Detail page Chapter menu Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 2
What is the difference between ICD-10-CM and ICD-10-PCS? ICD-10-CM codes are DIAGNOSIS codes: Used to describe the condition of the patient Reported in provider and hospital settings both CMS 1500 and CMS 1450 (UB-04) forms Corresponds to ICD-9-CM Volume 1 codes ICD-10-PCS codes are PROCEDURE codes: Used to describe the treatment provided to the patient Reported in facility setting CMS 1450 (UB-04) form Corresponds to ICD-9-CM Volume 3 codes Inpatient only Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 3
ICD-10-PCS (Procedural Coding System) Codes: Replacement for ICD-9-CM Volume 3 Codes ICD-10-PCS Format: Completely new code structure 7-character alpha/numeric codes All 7 characters must be specified to be a valid code No decimals Code format : Alphanumeric Digits 0-9 Letters A-H, J-N, P-Z Note the letters i and o have been omitted to limit confusion Increased specificity Detailed specificity will require coders to be knowledgeable in anatomy and physiology Significant room for expansion Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 4
PCS Code Structure Seven alphanumeric characters (example 02RG38H) Each character is an axis /position of classification that specifies information about the procedure performed (image is for Medical Surgical Section) The position of each character within the code is a function of the code s definition Characters are interdependent Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 5
The table section is organized differently from ICD-9-CM tabular list No longer extensive lists of codes to select from Coder selects most appropriate table and constructs a valid code Table section is composed of rows that specify the valid combinations of code values (approx. 184 codes in this example The first three characters of the code determine the table The upper portion of the table contains a description of the first three characters of the code. Example: 02R Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 6
The first three characters of the code define the table First character = Section Identifies the general type of procedure Med/Surg, Imaging, Obstetrics, etc. Sixteen sections: Medical and Surgical section constitutes the bulk of the codes (61,898 of 71,924 total PCS codes in 2014) Second character = Body System* Thirty-one Body Systems *Depending on the section, the second character value may have a meaning other than Body System Third character = Root Operation Identifies the objective of the procedure Thirty-one different root operations The Root Operation drives the construction of the code Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 7
The last four characters build the unique and specific code Fourth character = Body Part Indicates the specific part of the body system on which the procedure was performed Fifth character = Approach Specifies the technique used to reach the site of the procedure There are seven different approaches Comprises three components The access location The method Type of instrumentation Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 8
The last four characters build the unique and specific code (cont d.) Sixth character = Device Used only to specify devices that remain after the procedure is completed Four general types of devices Grafts and Protheses Implants Simple or Mechanical Appliances Electronic Appliances Seventh character = Qualifier Contains unique values for individual procedures Example: Identify the destination site in a Bypass: Subclavian, Carotid, etc. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 9
Locate the appropriate table using the Index: 3, 2, 1 The purpose of the alphabetic index is to locate the appropriate table that contains all information necessary to construct a procedure code The alphabetical index reflects the structure of the tables Main Table Header Root Operation (3) Body System (2) General Type of Procedure / Section (1) The main index terms are based on the value of the third character within a code Root Operations, root procedure types or common procedure names Terms such as biopsy, angioplasty or colonoscopy do not describe root operations The index provides the correct root operation reference Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 10
First determine the Root Operation (character 3) The Root Operation is the objective of the procedure Composite Terms are NOT Root Operations (biopsy) Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 11
3: First determine the Root Operation (character 3) The Root Operation is the objective of the procedure Composite Terms are NOT Root Operations (angioplasty) Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 12
3: Next, determine the body system/anatomical site (character 2) The general body system such as Heart and Great Vessels, Endocrine System, etc. 1: By and large, the selection of characters 3 and 2 will determine character 1 Character one describes the general type of procedure (Med/Surg, Obstetrics, etc.) Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 13
Select the hyperlinked code within the Index to populate the table (or build using dropdown menus once familiar with root operation terms) Root Operation definition and explanations are displayed Interim code description is displayed Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 14
4, 5, 6, 7 Build the final code by selecting characters from the lower portion of the table Selections are made within one row The fifth character is the approach Approach Definitions (builds expertise) Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 15
4, 5, 6, 7 Build the final code by selecting characters from the lower portion of the table Selections are made within one row The sixth character is the device Device Definitions (builds expertise) Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 16
4, 5, 6, 7 Build the final code by selecting characters from the lower portion of the table Selections are made within one row The seventh character is a qualifier Qualifier is unique for individual procedures Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 17
How many permutations can one table build? If I choose 02RG vs. 02R7, what will my code look like? Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 18
Tabular Range Page shows the Whole Picture Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 19
Detail page consolidates information about the code onto one page Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 20
Once you are familiar with the tables, you are not required to use the index Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 21
Once you are familiar with the tables, you are not required to use the index Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 22
Thank you. Contact information Denise Smith, RN, BSN, CPC 801-982-3025 denise.smith@optum.com