ADVANCE for Health Information Professionals recently published an online article bylined by our own Deborah Neville, RHIA, CCS-P.

We’ve heard so much recently about the ICD-10 transition, on track for October 1 of this year, in regards to outpatient procedures and CPT codes. In this article, Deborah discusses ICD-10 in terms of PCS coding, or those procedures done in the hospital in an inpatient setting.

When it comes to coding inpatient procedures, coders must look for documentation describing 31 specifically defined root operations. Providers are not required to use these specific ICD-10-PCS terms, but their documentation must provide enough detail for coders to equate the documentation to the specific PCS definitions.

If the coder is not able to correlate documentation to defined PCS terms, the provider may be queried.

In summary, the article outlines key documentation tips for coding procedures including the following: 

  • Describe the procedure. Eponyms are no longer used (e.g., Whipple procedure). Documentation must describe each component.
  • Be as specific as possible when documenting the body system or body part (e.g., the vessel, bone, nerve, or lobe of the lung).
  • Provide the laterality as this information is necessary to identify the specific site.
  • Specify when the same operation is performed on different body parts and specifically identify each body part.
  • Distinguish when different procedures are performed on the same body part for different reasons (e.g., excision of a colonic lesion and creation of a colostomy site).
  • State when and why a procedure was converted from a laparoscopic surgical procedure to an open procedure.
  • Document when a diagnostic biopsy is performed prior to an open procedure, rather than as a component of a definitive treatment, if performed to determine the medical necessity to proceed with the open procedure.
  • Indicate the sites “to” and “from” for bypass procedures.
  • Define the type of grafts and material used for instance, skin and blood vessel.

It’s important to note that all medical and surgical procedures that are performed in the inpatient setting must have an associated diagnosis that describes the medical necessity of the procedure and supports the need for the procedure to be done in the inpatient setting.  Medical necessity is a regulatory word that simple asks “why” — why did you need to do the procedure and why did the patient need to be admitted?

The article also sites several great resources available to coders such as the ICD-10-PCS Official Guidelines for Coding and Reporting, ICD-10-PCS Reference Manual, and the various appendices that assist coders in assigning appropriate body parts and devices.

In closing, it brings up a good point: ICD-10-PCS coding is new to everyone – including leading experts in the field like Deborah – but using these documentation tips and the tools available will streamline the process of assigning the proper codes, ensuring accuracy and maintaining productivity.

Deborah Neville is director of Revenue Cycle, Coding and Compliance for Elsevier Clinical Solutions. To read the entire article,