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Chapter 49 intro pro
introduction to icd-10-pcs procedure coding
| Term | Definition |
|---|---|
| Expandability | means that the structure of the code set allows new procedures to be easily incorporated. |
| Completeness | means that there should be a unique code for every procedure that is significantly different in body part, approach, or method. In ICD-9-CM Volume 3, the same code is sometimes used to describe procedures on different body parts, with different approaches |
| multiaxial nature of PCS codes | means that each position or character within a code number has a designated meaning or purpose. Each position is defined to be used for that meaning for all related codes and, to the extent possible, for all codes in the manual. |
| Standardized Terminology | means that the code set includes definitions of the terminology it uses; each term must have only one meaning. |
| Structural Integrity | means that ICD-10-PCS can be expanded easily without disrupting the structure of the system. The values of the seven characters that make up a code can be assigned as needed. |
| Clinical documentation improvement (CDI) | is a program implemented by many hospitals that educates physicians and helps them achieve complete documentation that accurately reflects the care patients receive. |
| CDI specialists | review patients’ charts concurrently (while the patient is in the hospital) and retrospectively (after the patient is discharged) to identify missing or inadequate documentation and query the physician for clarification when needed. |
| Significant procedures | are those that are surgical in nature, carry a procedural risk, carry an anesthetic risk, or require specialized training. |
| principal procedure | is one that was performed for definitive treatment, rather than one performed for diagnostic or exploratory purposes, or was necessary to take care of a complication. |
| Charge capture | is the process of entering the nonprocedural services provided throughout the patient stay, which is best done through a computer at the time the service is provided. |
| revenue code | a four-digit code that identifies a general category of service (are used to summarize charges on the final inpatient bill.) |
| charge description master (CDM) | assigns the charge to a revenue code, a four-digit code that identifies a general category of service, such as accommodation (room charge), type of ancillary service, pharmacy, or supplies. |
| Diagnosis related groups (DRGs) | are a payment system that categorizes patients who are medically related with respect to diagnosis and treatment and statistically have similar lengths of stay. they also tend to have similar costs and charges associated with the hospitalization. |
| Medicare Severity-adjusted DRGs (MS-DRGs) | consist of approximately 500 DRG classifications that aggregate the thousands of diagnoses and procedures available in the coding manuals. |
| Case-based | means that the rate is determined per case, or per inpatient admission, rather than on a per diem (daily) basis or a fee-for-service basis |
| Prospective payment | means that a standard payment rate is predetermined based on the average amount of staff, supplies, and other resources typically used and assigned to each DRG. |
| reimbursement method | places the risk of cost-effectively managing the patient’s stay on the hospital rather than the payer. |
| Cost outliers | are unusual cases in which the cost is above or below a standard threshold amount established for the DRG. |
| High cost outliers | can qualify for additional payment; low cost outliers can be paid a lower-than-usual rate. |
| DRG grouper | is software that considers several clinical and demographic characteristics of a patient. |
| 837I | The electronic billing format for institutions |
| UB-04, also known as the CMS-1450 | The standard hospital billing form |
| Repair | restoring a body part to its normal structure. |
| Replacement | putting in a device that replaces a body part. |
| occurrence codes, condition codes, and value codes | Some fields require unique two-digit indicators to communicate information to the payer |
| Condition codes | identify certain events or circumstances related to a patient. For example, if a condition is employment-related, the biller enters condition code 02 in the first available field of FL 18–28. |
| Occurrence codes and occurrence span codes | are used to identify a significant event that could affect payer processing. . |
| Occurrence codes and occurrence span codes | For example, if an accident or injury caused the condition being treated, the biller enters occurrence code 01 and the date of the accident in the first available field of FL 31–34 |
| Value codes | are entered in FL 39–41 and identify the number and dollar amount of certain services provided. |
| Value codes | For example, if a patient has physical therapy visits, the biller enters the value code 50 in the Code column on the left side of FL 39a and the actual number of physical therapy visits in the Amount column for FL 39, for example, 5 for five visits. |
| Revenue codes | are entered in FL 42, lines 1 to 22, with related service and charge information in FL 43–48. This information summarizes charges by department. An itemized bill showing each individual charge item is submitted with the claim. |
| FL 66 | is used to identify the coding system being used on the claim, such as 9 for ICD-9-CM or 0 for ICD-10-CM. |
| patient’s principal diagnosis | is entered in FL 67, with additional diagnoses in FL 67A–67Q. The admitting diagnosis appears in FL 69. |
| principal procedure | is entered in FL 74 and additional procedures in FL 74a–74d. |
| values | Coders select individual letters and numbers in a standard order to occupy the seven characters of the code. |
| Tables | are reference grids used to select the body part, operative approach, and other characteristics of the procedure. |
| Section | broad procedure category where the code is found. |
| Body System | in which the procedure is performed |
| Root Operation | or the objective of the procedure. |
| Body Part | or specific anatomic site where the physician performed the procedure. |
| Approach | or the surgical technique used to reach the procedure site. |
| Device | left in place at the end of the procedure |
| Qualifier | which describes additional information about the procedure. |
| Introduction in the ICD-10-PCS coding manual | identifies the character meanings for each Section. |
| appendix in most ICD-10-PCS manuals | provides a complete listing of all the Characters for all Sections. |
| first character in all PCS codes | describes the Section, or the broad procedure category, where the code is found (Table 49-5). The largest Section is Medical and Surgical. |
| second character in the Medical and Surgical Section | identifies the Body System, the general physiological system or anatomic region involved, such as central nervous system or endocrine system. The Medical and Surgical Section has 31 possible values for the Body System. |
| third character in the Medical and Surgical Section, and most other Sections, | defines the Root Operation, which describes the objective of the procedure (excision, destruction, extraction). The options and values for Character 3 vary from one Section to the next and from one Body Part value to the next within a Section. |
| Root Operations | are Main Terms in the Index, so coders must be familiar with their names and definitions. |
| Excision | is defined as cutting off a portion of a body part without replacement |
| Resection | is defined as cutting off all of a body part without replacement. |
| fourth character in the Medical and Surgical Section | identifies the Body Part, or specific anatomic site, where the physician performed the procedure. The Body System (Character 2) provides a general indication of the procedure location. |
| T Resection | defined as cutting out, without replacement |
| B Excision | cutting out, without replacement, a portion of a body part, and match it with the less specific Body Part value E Large Intestine |
| fifth character in the Medical and Surgical Section | defines the Approach, or the surgical technique used to reach the procedure site, such as open, endoscopic, or external. |
| sixth character in the Medical and Surgical Section | defines the Device left in place at the end of the procedure for those procedures that involve a device. Device values fall into four basic categories: grafts and prostheses, implants, simple or mechanical appliances, electronic appliances. |
| seventh character in the Medical and Surgical Section | defines a Qualifier for the code. A Qualifier specifies an additional attribute of the procedure, if applicable. |
Created by:
potier.brooke
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