ICD-10-PCS codes consist of seven characters, each of which identifies a unique, specific piece of information. For most of the codes in the Medical and Surgical section, each character represents the same information every time.
The fifth character in every code identifies the approach. In the Medical and Surgical section, coders will find seven different approach characters composed of three components:
- Access: The skin or mucous membranes and external orifices are the two types of access locations, says Laura Legg, RHIT, CCS, AHIMA-approved ICD-10-CM/PCS trainer, and HIM director at Healthcare Resource Group in Spokane Valley, Washington. All approaches except external include one of these two access locations. The physician can cut or puncture the skin or mucous membrane to reach the procedure site. All open and percutaneous values use this access location. Access through an external opening can involve either a natural or artificial orifice.
- Location: Instrumentation is the specialized equipment used to perform the procedure, Legg says. All internal approaches require instrumentation. Endoscopic refers to approach values that permit the site to be visualized.
- Method and instrumentation: With procedures on an internal body part, method specifies how the external access location is entered, Legg says. The open method specifies cutting through the skin or mucous membrane to expose the site of the procedure.
Defining the approach
"The approach identifies the technique used to reach the procedure site," says Nena Scott, MS, RHIA, CCS, CCS-P, director of education at TrustHCS in Springfield, Missouri. "There are different approaches based upon each section."
In the Medical and Surgical section, coders will choose between the following approaches:
- An open approach (character value 0) is defined as cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure. The access location for this approach is through either the skin or a mucous membrane. The type of instrumentation used is not applicable, Scott says.
Physicians don't have to specify "open" in the name of the procedure. For example, a physician may describe an abdominal hysterectomy. The procedure is not defined as "open," but in the operative report, the surgeon describes cutting through the skin to reach the uterus in order to remove it. If the procedure is performed vaginally, then the approach is not open.
- A percutaneous approach (character value 3) involves entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure. The access location for this approach is the skin or mucous membrane with nonvisualization instrumentation such as needles or catheters being used to reach the operative site. Biopsies can be done via the percutaneous approach when the physician uses a needle to perform the procedure.
- A percutaneous endoscopic approach (character value 4) is defined as entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure. The access location for this approach is the skin or mucous membrane with visualization instrumentation being used to reach the operative site. Laparoscopic procedures are the most common procedures using this approach.
- An approach made via either a natural or artificial opening (character value 7) is defined as entry of instrumentation through a natural or artificial external opening to reach the site of the procedure. The access location for this approach is an orifice with nonvisualization instrumentation being used to reach the operative site. This would include an orifice, such as a nose, ear, or rectum. It would also include an artificial external opening, such as a colostomy. This approach includes instrumentation without visualization. Therefore, an endoscope would not be used to visualize the procedure. An example is insertion of an endotracheal tube, which is done through the mouth without use of an endoscope.
- A natural or artificial endoscopic approach (character value 8) is defined as entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure. The access location for this approach is an orifice with visualization instrumentation being used to reach the procedure site. The access location is still through an orifice, but the difference from the previous approach is the visualization. An example is a sigmoidoscopy. Here, an endoscope is inserted into the rectum to view the sigmoid colon.
- An approach made via natural or artificial opening with percutaneous endoscopic assistance (character value F) is defined as entry of instrumentation through a natural or artificial external opening and entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to aid in the performance of the procedure. For this approach, the access location is the skin or mucous membrane. The instrumentation is with visualization (endoscope). An example is a laparoscopic-assisted vaginal hyster-ectomy. In this procedure, the uterus is removed via the vagina, but a laparoscope is used to assist in the procedure.
- An external approach (character value X) is one in which the procedure is either performed directly on the skin or mucous membrane or indirectly by application of external force through the skin or mucous membrane. The method used is direct or indirect application of external force, and no instrumentation is used. An example is a closed fracture reduction.
Each table in ICD-10-PCS also has different combinations of possible approaches. For example, a physician may remove the prostate using any of these approaches:
- Open
- Percutaneous
- Percutaneous endoscopic
- Via natural or artificial opening
- Via natural or artificial opening endoscopic
For a resection of the sternum, however, the physician can only use an open approach. That is the only value available in the ICD-10-PCS table.
For removal of an upper tendon, the surgeon can use:
- Open
- Percutaneous
- Percutaneous endoscopic
ICD-10-PCS does not include a choice for a minimally invasive approach because this term cannot be defined, says Gretchen Young-Charles, RHIA, senior coding consultant for the American Hospital Association in Chicago.
"There is no consensus among physicians on a definition," Young-Charles says.
The object of minimally invasive surgery is to leave the body as intact as possible. In order to determine the correct approach, coders must refer to the definitions of the approaches in ICD-10-PCS, Young-Charles says.
Approach guidelines
ICD-10-PCS includes specific guidelines to help coders identify the correct approach.
For example, if the physician performs a procedure using an open approach with percutaneous endoscopic assistance, report the approach as open (guideline B5.2), Scott says.
An example is a laparoscopic-assisted sigmoidectomy. Although a laparoscope is used to perform the procedure, an incision is also made; therefore, the procedure warrants an approach value of open.
Guideline B5.3a states, "Procedures performed within an orifice on structures that are visible without the aid of any instrumentation are coded to the approach external."
"Resection of the tonsils is coded to the external approach," Scott says. Coders might think "external" means "outside of the body" and conclude that the tonsils are not external structures. However, because the procedure is done through an orifice without any instrumentation, the approach is external.
If the physician performs the procedure indirectly by applying external force through the intervening body layers, use external as the approach (guideline B5.3b).
"A closed reduction of fracture is coded to the external approach," Scott says.
When coding a fracture reduction, be sure to read the entire operative report, not just the title, Scott adds. Physicians may title the procedure "open reduction internal fixation" when they are actually performing a closed reduction and making the incision only after they reduce the fracture.
For a closed reduction, the approach is external. If the physician makes the incision before moving the bone back into place, use open for the approach. If the physician performs the procedure percutaneously via a device placed for the procedure, report a percutaneous approach (guideline B5.4).
Fragmentation of kidney stone performed via percutaneous nephrostomy is coded as a percutaneous approach, Scott says.
Not always obvious
In most cases, the approach should be clear from the operative report. However, that's not always the case.
A female patient suffered a second-degree perineum laceration. The physician repaired the tear by suturing the muscle. Which approach should be reported?
For this case, the approach is open even though the physician did not cut down to the muscle, says Young-Charles. "As long as the site is exposed and you can see it, the approach is open," she says. "It doesn't matter how the site was opened."
Another example is a laceration of the liver due to a knife wound. Because the knife wound opened the area and the physician could see the liver, coders would use the open approach character, Young-Charles says.
Editor’s note: This article was originally published in the November issue of Briefings on Coding Compliance Strategies.Email your questions to Senior Managing Editor Michelle A. Leppert, CPC, at mleppert@hcpro.com.