Prepare for increased queries in ICD-10-PCS

In ICD-10-PCS every character has to have a value.

"You don't have the option of putting a Z wherever you want just because you don't know that value," says ACDIS Advisory Board member Cheryl Ericson, MS, RN, CCDS, CDIP, CDI education director for HCPro, a division of BLR, in Danvers, Massachusetts.

The biggest growing pain is figuring out what CDI specialists will need to query for, Ericson says. "We have to find that threshold of when are we nitpicking versus what's relevant."

Surgeons receive very few queries right now and many involve excisional debridement. In addition, CDI specialists rarely query surgeons for diagnoses, Ericson adds. They usually query hospitalists about diagnoses because hospitalists are involved in treating the patient. However, only the surgeon can answer questions about the procedure.

Getting a query in front of a surgeon could also be a problem, Ericson says, especially with electronic medical records (EMR). Surgeons are paid on a global rate, so they don't need to evaluate the patient on a daily basis. They do still stop by and check on the patient, but "you don't get a lot of information because they are not being paid to do that daily assessment," Ericson says.

Coders and CDI specialists will not need additional information for every surgical case, of course, and some of the characters will be obvious.

For example, coders should be able to determine the section of the ICD-10-PCS Manual fairly easily. The majority of procedures fall into the Medical and Surgical section.

Other information, such as the body system, body part, root operation, and approach, may not be so simple to determine, says Lynn Salois, RHIT, CCS, CDIP, senior director of coding for MRA in Quincy, Massachusetts.

For example, in ICD-10-PCS, the surgeon needs to be much more specific about which portion of the intestine was removed. The table for colon resection (0DT) includes specific body part characters for:

• Large intestine
• Right large intestine
• Left large intestine
• Cecum
• Ascending colon
• Transverse colon
• Descending colon
• Sigmoid colon

The body part specificity may also affect root operation selection. Root operations excision and resection both involve cutting out or off, without replacement. The only difference is that an excision removes a portion of the body part, while a resection removes the entire body part.

If the physician documents a resection of the large intestine, coders don't know whether the physician removed the entire intestine (resection) or only part of the large intestine (excision). If the physician removed the entire right large intestine, coders are back to root operation resection.

"Excision and resection are going to be a definite problem area because you have to know how the body part is defined by ICD-10-PCS, which may or may not include parts of the whole organ," Ericson says.

The specificity of the body parts will create a problem for surgeons. Unlike pictures in textbooks, actual large intestines do not have indicators to show where the ascending colon ends and the transverse colon begins.

Amputations will be another troublesome procedure, Ericson says. For detachment procedures of the lower limb, physicians must document where the detachment occurred:

• Hindquarter
• Femoral region
• Knee region
• Upper leg
• Lower leg

When the site isn't defined as the hindquarter, femoral, or knee region, then the detachment requires reporting a qualifier character of high, mid, or low to identify the level of the amputation. The physician documentation will need to be very clear so coders can select not only the correct body part, but also the correct qualifier, Ericson says.

Physicians don't need to understand the root operation types or document the root operation name. ICD-10-PCS guideline A11 states:

It is the coder's responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear.

"We really need the physicians to describe the procedure that's being performed so that the coder can then accurately translate those clinical terms to the root operations," Salois says.

Coders may also struggle to determine the approach. ICD-10-PCS includes seven different approaches, but not all can be reported for every procedure. "The surgeons need to be very, very clear in their documentation," Salois says.

Devices are another potential problem area, Salois says. ICD-10-PCS defines devices in a very specific way. Only material that is integral to the procedure or remains in the patient after completion of the procedure in a fixed location (i.e., isn't absorbed or incorporated into the body) is classified as a device.

Six root operations always require a device character other than Z (no device). Those devices are very specific in nature.

For example, if the physician repositions a lower leg bone, coders have the following device choices:

• Internal fixation device
• External fixation device
• Internal fixation device, intramedullary
• External fixation device, monoplanar
• External fixation device, ring
• External fixation device, hybrid
• No device

If CDI specialists are reviewing records concurrently, they can identify missing documentation and reach out to the surgeon.

However, if no one reviews the documentation concurrently, a coder may be the one who finds information missing after the patient is discharged. Depending on the turnaround time at the coder's facility, that discovery could come as many as 10 days after the surgeon performed the procedure.

"We've created a situation where you have to query retrospectively and the physician may not be approachable or available," Salois says. 

Coders and CDI specialists can do some additional work on their end to prepare for ICD-10-PCS. Consider inviting physicians to explain procedures to coders and CDI specialists. This can help train coders and CDI specialists, reduce the number of queries, and build relationships between surgeons and coding staff.

Remind physicians that they don't need to change the way they document, Salois says.

"It's really important that we understand and respect the workflow of the surgeons," Ericson adds—that might mean working different hours. "We have to adjust our workflow to accommodate them."

Be creative in getting surgeons on board with answering queries, Ericson says. For example, many surgeons use boilerplate language for their operative notes. Find out if the surgeons will allow modifications to the boilerplate to capture information about specific anatomic locations or device types, she says.

Also consider adding prompts to the EMR or modifying those templates, Salois says. Compare the information currently captured in the EMR to the information needed to assign an ICD-10-PCS code. See where the gaps are and begin to develop queries from there, she adds.

Editor’s note: This article was originally published in the June issue of Briefings on Coding Compliance Strategies.