By Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA
Many articles have been published regarding the need for enhanced documentation for ICD-10-CM/PCS. Many of these articles have focused primarily on ICD-10-CM. However, the real challenge will be ICD-10-PCS.
ICD-10-PCS does not include unspecified codes. Thus, clinicians may see an increased number of queries on procedures post-implementation. Clinical documentation improvement (CDI) professionals, inpatient coders, and clinicians should focus one several important documentation areas during the next year to prepare for ICD-10-PCS implementation.
Coders must understand that physicians are not obligated to use root operation terminology in their documentation. The 2014 ICD-10-PCS Official Guidelines for Coding and Reporting state the following:
Many of the terms used to construct PCS codes are defined within the system.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.
Example: When the physician documents “partial resection” the coder can independently correlate “partial resection” to the root operation Excision without querying the physician for clarification.
Inpatient coders and CDI specialists must be proficient in the ICD-10-PCS root operation definitions and be able to apply the correct root operations for procedures performed within their facilities.
By learning the root operations now, they can identify and remedy any gaps in documentation prior to implementation. Working collaboratively with clinicians during this timeframe is an important part of ensuring that documentation is ready for the nuances of ICD-10-PCS.
Anticipated documentation gaps
Each hospital may have its own specific documentation areas that require improvement for ICD-10-CM/PCS. Following is a list that hospitals can use to begin reviewing current documentation. Note that this is not a comprehensive list and that hospitals must perform a detailed gap analysis to determine which specific conditions and procedures require remediation.
Lymph nodes: excision vs. resection
In ICD-10-PCS, the lymph node is considered to be part of a chain. For example, the thorax area includes five lymph node chains:
- Pulmonary
- Juxtaesophageal
- Bronchopulmonary (Hilar)
- Superior tracheobronchial
- Inferior tracheobronchial
- Paratracheal
Each of these five chains includes multiple lymph nodes. The documentation in the operative report must clearly state whether all or some of the nodes within each chain are removed. When the physician cuts out an entire lymph node chain, the appropriate root operation is resection. If the physician removes only a portion of the chain, the root operation is excision. Consider the following definitions:
- Excision: cutting out or off, without replacement, a portion of a body part
- Resection: cutting out or off, without replacement, all of a body part
Physicians must provide the specific location of an amputation. ICD-10-PCS classifies this procedure as detachment (cutting off all or part of the upper or lower extremities).
For amputations of the humerus, femur, radius/ulna, or tibia/fibula, coders must know whether the amputation occurs at the proximal, middle, or distal portion of the shaft.
When coding amputations of the hand or foot, coders must know whether a complete or partial amputation is performed.
A complete amputation is through the carpometacarpal joint of the hand or through the tarsal-metatarsal joint of the foot. A partial amputation is anywhere along the shaft or head of the metacarpal bone of the hand, or of the metatarsal bone of the foot.
Embolization: restriction vs. occlusion
Physicians may perform embolization procedures to restrict or occlude a vessel. The documentation must clearly state the intent of the procedure so that coders can select the correct root operations. Coders should familiarize themselves with the following ICD-10-PCS guideline:
B3.12. Occlusion vs. Restriction for vessel embolization procedures
If the objective of an embolization procedure is to completely close a vessel, the root operation Occlusion is coded. If the objective of an embolization procedure is to narrow the lumen of a vessel, the root operation Restriction is coded.
Examples: Tumor embolization is coded to the root operation Occlusion, because the objective of the procedure is to cut off the blood supply to the vessel.
Embolization of a cerebral aneurysm is coded to the root operation Restriction, because the objective of the procedure is not to close off the vessel entirely, but to narrow the lumen of the vessel at the site of the aneurysm where it is abnormally wide.
The intent of the procedure will determine whether coders report one of the following root operations:
- Restriction: partially closing an orifice or the lumen of a tubular body part
- Occlusion: completely closing an orifice or the lumen of a tubular body part
In ICD-10-PCS, coronary arteries are classified as a single body system. Coders must know the number of sites treated—not the specific branch of coronary artery treated. This is especially important to remember for coding dilation and bypass procedures during which the physicians treats multiple sites.
For bypass procedures, the physician must document type of device that he or she uses during the procedure (e.g., autologous venous tissue). If the physician harvests an autograft, coders must report a separate ICD-10-PCS root operation/code (i.e., excision) which also requires specific documentation. The physician must document the type of device used in the dilation procedure (e.g., drug-eluting stent, radioactive stent) so coders can assign the correct code.
Consider the following relevant root operations:
- Dilation: expanding an orifice or the lumen of a tubular body part
- Bypass: altering the route of passage of the contents of a tubular body part
Cardiac catheterization procedures present their own list of documentation opportunities. Coders must know the following information to assign codes accurately:
- Left, right, or combined heart catheterization
- Arteriography and/or ventriculography performed
- Type of contrast used during the procedure (i.e., high osmolar, low osmolar, or other)
A quick look at current cardiac catheterization reports will indicate whether these procedures require documentation improvement at your hospital.
Focus on quality clinical documentation—not necessarily improving large volumes of documentation. Sufficient documentation must exist to support code assignment while also allowing clinicians to document in clinical—not coding—terms. Coders, CDI specialists, and clinicians must collaborate to achieve this goal.
Facilities should take this final year to perform a deep dive into their current documentation and identify areas that require improvement. Once gaps are identified, focus educational efforts on specific groups that require the training.
Take advantage of this time to grow trust and respect between CDI specialists, clinicians, and coders. These three groups all bring important pieces of knowledge to the table. Working collaboratively will benefit the quality of patient health record documentation which, in turn, enhances patient care and provides accurate reimbursement to both the facility and the clinician.
Editor’s note: Endicott is the director of HIM practice excellence at AHIMA in Chicago.