Correctly code for multiple procedures in ICD-10-PCS

Almost everything about ICD-10-PCS will be new for inpatient coders. That includes the guidelines for reporting multiple procedures.

The ICD-10-PCS Official Guidelines (B3.2) address these four specific circumstances when coders will report multiple procedures:

  • Same root operation is performed on different body parts as defined by distinct values of the body part character
  • Same root operation is repeated at different body sites that are not included in the same body part value
  • Multiple root operations with distinct objectives are performed on the same body part
  • Intended root operation is attempted using one approach, but is converted to a different approach

Additional guidelines will also apply when a provider performs multiple procedures and they are included in other sections of the ICD-10-PCS guidelines.

Physicians need to be clear about the intent of the procedure, the approach, the body part, the location, and any devices they leave behind, says Mark N. Dominesey, MBA, RN, CCDS, CDIP, HIT Pro-CP, director of auditing and clinical documentation improvement services for TrustHCS in Springfield, Mo.

Those factors will come into play when coders are determining whether to report one procedure or multiple procedures.

Same root operation, different body part

ICD-10-PCS codes are divided first by body system (e.g., lower veins, gastrointestinal system), then further subdivided into specific body parts (e.g., ascending colon, transverse colon). The ICD-10-PCS tables are segmented by body system.

According to the ICD-10-PCS guidelines, if a physician performs multiple procedures on different body parts within the body system, coders report all of the procedures separately.

For example, if a physician drains fluid from both the right parotid gland and the right parotid duct, coders would report each procedure separately. The ICD-10-PCS table 0C9 for drainage procedures of the mouth and throat includes separate body parts for the right parotid gland and right parotid duct.

If the physician performed the drainage through a percutaneous approach, coders would report:

  • 0C9830Z, percutaneous drainage of the right parotid gland
  • 0C9B30Z, percutaneous drainage of the right parotid duct

This guideline could potentially impact reimbursement, says Jennifer Avery, CCS, CPC-H, CPC, CPC-I, regulatory specialist for HCPro, Inc., in Danvers, Mass.

Similar procedures performed on different body sites

In some cases, two separate and distinct procedures can be represented by the exact same code. When that happens, the ICD-10-PCS guidelines instruct coders to report the code twice.

For example, a surgeon repairs a torn left posterior cruciate ligament (PCL) and a left lateral collateral ligament (LCL) by open approach during the same operative session.

The ICD-10-PCS table 0MQ (repair of bursae and ligaments) contains one body part for right knee ligaments (N) and one for left knee ligaments (P). It doesn’t actually include a body part value for the four individual ligaments of the knee.

Because the physician actually performed two different procedures on two different ligaments, coders would report:

  • 0MQP0ZZ, repair of left knee bursa and ligament, open approach
  • 0MQP0ZZ, repair of left knee bursa and ligament, open approach

Outpatient coders don’t face the same problems because CPT includes modifiers to specify that a physician actually performed two procedures. Coders have no way to show they are actually reporting separate procedures in ICD-10-PCS.

Multiple operations on the same body part

A physician may perform multiple procedures with different objectives on the same body. Coders use the objective of the procedure to determine which root operation to report. When the physician performs procedures with different objectives on the same body part, coders will code each procedure separately.

This guidelines could cause some confusion because its application appears to differ from current coding practice.

This appears to be the case when physicians perform lysis of adhesions. If the physician documents an open partial descending colon resection with enterolysis of large intestinal adhesions, coders would report:

  • 0DBM0ZZ, excision of the descending colon (the open partial descending colon resection)
  • 0DNE0ZZ, release of the large intestines (enterolysis of large intestinal adhesions)

Currently, enterolysis of adhesions is considered a part of the procedure unless the physician identifies that the adhesions unusually complicated the procedure in some way, Avery says.

“However, based on the ICD-10-PCS guidelines, it appears as if we would be able to report them separately,” she adds. “I believe that we will see more on this in the near future: Is the enterolysis really being performed to free the body part, or is it an integral part of the more definitive procedure?”

Avery encourages coders to submit questions to AHA's Coding Clinic and ask if this is a change from how coders code in ICD-9 or whether the physician still have to identify how they ‘unusually complicate’ the procedure. 

The ICD-10-PCS guidelines specifically reference destruction of a lesion with an additional procedure. The guidelines state: “Example: Destruction of sigmoid lesion and bypass of sigmoid colon are coded separately.”

Procedures that begin with one approach but are converted to another

The final multiple procedure guideline in ICD-10-PCS involves procedures that the physician begins using one approach, but changes the approach during the procedure. A common example is a laparoscopic cholecystectomy converted to an open cholecystectomy.

In ICD-9-CM, coders only report the open cholecystectomy with a procedure code and add a diagnosis code (V64.41) to indicate that the physician changed the approach.

In ICD-10-PCS, coders will report two distinct procedures: one for the open procedure using the root operation for the intent of the procedure and an inspection procedure to represent the laparoscopic procedure.

For the laparoscopic cholecystectomy converted to an open procedure, coders would report:

  • 0FJ44ZZ, inspection of gallbladder, percutaneous endoscopic approach
  • 0FT40ZZ, resection of gallbladder, open approach

Do not report a percutaneous endoscopic resection of the gallbladder and an open resection of the gallbladder. Almost all patients only have a single gallbladder and reporting two different approaches for the same procedure will raise red flags with payers.

“This guideline is going to take many of us by surprise and we’ll need some time to get comfortable using it,” Avery says.

 Email your questions to Senior Managing Editor Michelle A. Leppert, CPC, at mleppert@hcpro.com.

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