Surgery is the top moneymaker for most hospitals and health systems. The correct charging, coding and billing of inpatient surgical encounters is paramount to healthy revenue cycles and positive cash flows, considering 60 to 70% of a hospital’s revenue is tied to the operating room. However, in 2014 providers may face their greatest surgical challenge yet: ICD-10-PCS.
This article lays out six steps for HIM directors and coding managers to effectively prepare their coding staff for ICD-10-PCS. From tackling root operations to evaluating surgical service-line GEMS, the tips and techniques described in this article ease the way from operative coding in ICD-9 to ICD-10-PCS.
Six Steps to Learning ICD-10-PCS
At AHIMA’s 85th Convention & Exhibit, the need for coders to master ICD-10′s Procedural Classification System (PCS) was universally discussed. Conversations ranged from educating surgeons on new terms to helping coders translate physician speak into ICD-10 codes. These six key steps were identified as essential precursors to learning ICD-10-PCS:
Step One: Tackle Root Operations
Within ICD-10-PCS, there are new terms and definitions related to surgical procedures. These new terms are used throughout 31 root operations and are easily divided into nine groups of similar procedures, each with their own specific definition.
Each group’s definition describes the “goal” or “outcome” of the individual surgical procedure. From there, each step within a surgical episode must be identified and coded using one of these terms based on the goal or outcome of the step.
The easiest way for coders to understand ICD-10-PCS is to separate the 31 root operations into the nine groups, then learn the finer nuances of each procedure. A simple table such as this one may become clinical coders’ new best friend.
With the main surgical groupings table in hand, coders should take the next step: dive deeper into each definition. There are unique differences among the 31 root operations that must be understood and correctly coded. Flash cards may re-emerge as reminders of new root operation definitions.
To assign the correct root operation, coders should skim operative reports, find key words and phrases, and then translate surgeons’ documentation into correct ICD-10 codes. For example, in ICD-10, excision is the cutting out of “some” of a body part while resection is the cutting out of “all” of a body part. The finer nuances of each operative step are critically important in ICD-10.
Using crosswalk tip sheets for the most common surgical procedures is another simple tool for coders to learn ICD-10-PCS’s root operations. Here is one example:
Thrombectomy = Extirpation
Thoracentesis = Drainage
Fracture Reduction = Reposition
D&C = Extraction
Biopsy = Excision
Amputation = Detachment
Nephrectomy = Resection
Step Two: Learn How to Read OR Reports
In ICD-9, coders could assign surgical codes by referencing the OR report title and high-level description. In ICD-10, coders must take the time to read operative reports and interpret the specific surgical documentation. They must find details not currently needed in ICD-9. The bottom line: surgical details change clinical codes.
Guideline A11 further explains that it is the coder’s responsibility to determine what the documentation in the medical record equates to in the PCS definitions. Physicians are not expected to use PCS code descriptions. Instead, coders are empowered to translate OR documentation into defined PCS terms versus querying surgeons when correlations are clear.
Coders must rise up to this new responsibility and achieve a higher comfort level in interpreting physician documentation, or queries will surge and productivity will tank.
Here are six tips to expedite the reading of OR reports:
Finally, it should be noted that physicians must provide timely and thorough OR reports for effective coding in ICD-10-PCS. Five lines are not sufficient for an operative report. HIM directors and CDI teams should work together in 2014 to ensure that surgeons, rarely queried in ICD-9, are aware of new documentation requirements.
Step Three: Transition from Digits to Characters
ICD-10-PCS codes contain seven characters, not digits. Each character provides a specific piece of information and each must be present to constitute a complete code. This represents a fundamental shift for coders as they focus on assigning each character versus the overall numerical code.
To assist, organizations should state within their coding guidelines how many ICD-10-PCS codes must be assigned. For example, ICD-9 has one CPT code for a polypectomy during colonoscopy, regardless of the number of polyps. In ICD-10-PCS, each polyp could potentially be coded.
Step Four: Write Effective Surgical Queries
Unless coders feel empowered to translate surgeon documentation within the OR report to ICD-10-PCS terms, query volumes will explode. To prevent this, follow Guideline A11 mentioned above and only query for items needed for the specific code – site of the procedure (which nerve, artery, etc.), laterality, approach technique, and device inserted. In most cases, this information should be included within a thorough OR report. Only when not present should the physician be queried.
When queries are absolutely necessary, write them in “surgeon speak” and be very specific. Many organizations are already assessing their OR reports, identifying documentation gaps, and updating physician queries accordingly.
Step Five: Understand the Role of CPT
During one of the educational sessions at AHIMA, the audience was asked if they would use ICD-10-PCS for both outpatient and inpatient surgical procedures. As the Medicare guidelines currently stand, outpatient surgical procedures do not need an ICD-10-PCS code; they only require a CPT code alongside an ICD-10-CM diagnosis code. However, approximately 50% of the session’s attendees reported that they would assign both ICD-10-PCS and CPT codes for their outpatient surgical procedures.
Organizations should determine early in 2014 if they will or will not assign ICD-10-PCS codes to outpatient procedures as the additional coding volume has a dramatic impact on coder staffing and productivity.
Step Six: Evaluate Surgical GEMS
GEMS provide limited direct correlations for surgical coding in ICD-10-PCS. Therefore, organizations must carefully evaluate GEMS and use them with caution.
For example, the suture of an artery in ICD-9 has only one code, but there are 276 codes for the same procedure in ICD-10. GEMS can help coders identify where to begin looking for the correct code in ICD-10-PCS but should not be the sole source of code assignment. Coders should never rely on GEMS and assume the GEMS crosswalk between ICD-9 and ICD-10-PCS is correct.
Ready, Set, Go
Procedures are much more difficult to code than diagnoses in ICD-10. Additional coder training and documentation analysis is warranted. To effectively prepare, organizations should know what percentage of discharges includes a procedure and determine whether or not outpatient surgical cases will be assigned an ICD-10-PCS code. These statistics help identify coder productivity, physician query, and overall staffing impact for surgical coding in ICD-10.
Baseline anatomy knowledge, cheat sheets, and easy access to root operations tables are all valuable coder tools to minimize productivity drops and improve ICD-10-PCS accuracy. Surgical technicians are an excellent source for coder lunch-and-learns or procedure-specific knowledge sharing. Most important, coders need practice in reading OR reports and assigning ICD-10-PCS codes. Include surgical coding in all dual coding initiatives while ensuring that coders have everything they need: anatomy and physiology, ICD-10 fundamentals and terminology training.
In an era of declining surgical reimbursement, every dollar counts. For healthier bottom lines in ICD-10, organizations must ensure correct clinical coding of each surgical episode.
Gerri Walk is the Senior Manager of Technical Training at HRS, Baltimore, Md.