UHDDS definitions

Uniform Hospital Discharge Data Set (UHDDS) definitions are used by acute care, short-term hospitals to report inpatient data elements in a standardized manner. Definitions that pertain to the assignment of procedure codes are presented in the following sections.

Procedure Codes That Should Be Reported

Any procedures that affect payment or reimbursement must be reported. Other procedures may be reported at a hospital’s discretion or in accordance with hospital policy. Encoders (coding software) may also have special popup notices that alert the coder about noncovered or limited coverage OR procedures.

After assigning procedure codes, the coder should review the diagnosis codes to ensure the assignment of diagnosis codes that support the performance of a procedure.

The Centers for Medicare and Medicaid Services (CMS) has categorized procedures into different classifications through the Medicare Code Editor (MCE). In some code books, these procedures may be highlighted to facilitate assignment of procedure codes. The Medicare Code Editor is software that detects errors in coding on Medicare claims. For example, it would identify a male-only procedure coded on a female patient’s record.

During a patient’s hospitalization, it may be necessary for a procedure to be performed at an outside facility. This could be for reasons such as the service may not be offered at the admitting hospital or equipment may malfunction. The patient may be transported by ambulance to this outside facility, and after the procedure, return for continued care at the admitting hospital. In these cases, the admitting hospital may assign procedure codes for services performed at the outside facility. The admitting hospital also would include these charges on the hospital bill, and the admitting hospital would reimburse the outside facility for the procedure.

Surgical Hierarchy

The MS-DRG grouper software (computer program that assigns an MS-DRG), using diagnosis and procedure codes, identifies whether a particular patient falls into a medical MS-DRG or a surgical MS-DRG. The MS-DRG grouper is able to determine which procedure is the most resource intensive and assigns the procedure to that particular surgical MS-DRG.

Closed Surgical Procedures and Conversion to Open Procedures

As technology has advanced, procedures are increasingly being performed through scopes, which are less invasive than open procedures. This has resulted in quicker recoveries, shorter hospital stays, and fewer complications.

Common closed surgical approaches include laparoscopic, thoracoscopic, and arthroscopic procedures. The laparoscopic approach involves use of a laparoscope to examine and perform closed procedures within the abdomen. With a thoracoscopic approach, a thoracoscope is used to examine and perform closed procedures within the thorax. The arthroscopic approach requires the use of an arthroscope to examine and perform closed procedures within a joint. Closed procedures may be diagnostic and/or therapeutic in nature.

A surgical procedure may start with an endoscopic approach that may need to be converted to an open procedure. Some reasons for conversion to an open procedure include adhesions, bleeding, technical difficulties due to anatomic body structure and/or inflammatory changes, and injury to an organ. The reason for converting to an open procedure should be coded. According to ICD-10-PCS guidelines, two procedure codes are necessary: one for the endoscopic procedure and one for the open procedure. The root operation for the endoscopic procedure code may be inspection.

Planned and Canceled Procedures

When patients are admitted to the hospital for a scheduled procedure(s), under some circumstances, the procedure(s) may be canceled or not completed. If a patient’s procedure is canceled prior to the time that he or she presents to the hospital, no code will be required because no services were provided, no bill was generated, and there is no health record. On some occasions, a patient presents to have a procedure performed, but for whatever reason the procedure has to be canceled. The principal diagnosis in this case is the reason why the patient was going to have the procedure performed. If a complication arose that resulted in the cancellation, a diagnosis code for that condition would be assigned as a secondary diagnosis. Also, Z codes describe the reason for the cancellation. They can be located in the Index under the main term, procedure (surgical) not done.

Occasionally, a surgical procedure will be started that for whatever reason cannot be completed. The surgical procedure should be coded to the extent that it was performed. These circumstances are different from those surrounding a procedure that is canceled, in that the patient received anesthesia and surgery was begun.

Bilateral Procedures

A bilateral procedure occurs when the same procedure is performed on paired anatomic organs or tissues (i.e., eyes, ears, joints such as shoulder or knee). According to ICD-10-PCS guidelines, if the identical procedure is performed on contralateral body parts, and a bilateral body part value exists for that body part, a single procedure code using the bilateral body part value is assigned. If no bilateral body part value exists, each procedure is coded separately.

As procedures become less invasive, more bilateral procedures may be performed during the same operative episode.

Facility Policy

Each facility should have its own written policy regarding the assignment of ICD-10 procedure codes. This policy should consider reimbursement, but it should also take into account other uses of a procedure database and how that information can be extracted. It may be necessary to determine what types of procedures are being performed for physician profiles and credentialing. Research is an important aspect of data collection.

As has been stated previously, because not all procedures are performed in the operating room, it may be difficult to locate documentation of all procedures performed. Procedures that are easy to overlook include mechanical ventilation, debridement, lumbar puncture, suturing, ECMO (extracorporeal membrane oxygenation), and procedures performed by interventional radiology.

History of ICD-10-PCS

In 1992, the Centers for Medicare and Medicaid Services (CMS) funded a project to replace Volume 3 of ICD-9-CM, which was outdated and could not be expanded to classify procedures with more specific detail. 3M Health Information Systems was awarded a contract to develop a new system for procedural coding, ICD-10-PCS (Procedure Coding System). ICD-10-PCS was initially released in 1998. Since that time, it has been updated to incorporate changes that were made to ICD-9-CM, Volume 3. CMS is responsible for the maintenance of ICD-10-PCS. (Information about ICD-10-PCS is available on the CMS website.)

According to the National Center for Health Statistics (NCHS), the proposed implementation date for ICD-10-PCS is October 1, 2014.

Organization of ICD-10-PCS

All ICD-10-PCS codes are seven characters (no decimal points are used), with each character representing a particular aspect of the procedure. Each character is represented by a letter or a number and is referred to as a “value.” ICD-10-PCS codes are alphanumeric, so there are 34 possible values for each character, the numbers 0-9 and letters A-H, J-N, and P-Z. The letters I and O are not used in ICD-10-PCS.

Exercise 6-2

Answer the following questions about the characters in an ICD-10-PCS code.

Using the ICD-10-PCS, identify the section value for the following.

Using the Alphabetic Index only, identify the appropriate table for the following procedures.

Medical and Surgical Section

Because the Medical and Surgical section is the largest section, and the section that is used the most, we will use this section to learn more about the structure and standardized definitions that are utilized by ICD-10-PCS. The character value for the Medical and Surgical section is 0 (the digit, not the letter O). All the codes from the tables in the Medical and Surgical section begin with a zero.

The meanings of the seven characters for codes from the Medical and Surgical section are as follows: