Editor’s Note: This Practice Brief supersedes the June 2016 Practice Brief titled “Guidelines for Achieving a Compliant ICD-10-PCS Query.”
The integrity of the documentation within the health record is vital as it reflects the care, treatment, and services delivered to patients. Clinical documentation is at the core of every patient encounter. The documentation must be accurate, timely, and reflect the scope of services provided. Clinical documentation integrity (CDI) processes and practices facilitate the accurate representation of a patient’s clinical status and is converted to coded data. This coded data impacts quality reporting, reimbursement, public health data, patient care and research, and more.
The complex and highly specific nature of The International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) has changed the query process for inpatient procedures. Each code is constructed using individual characters that identify all aspects of the procedure. Assigning the correct ICD-10-PCS code requires accurate and complete documentation. Incomplete and non-specific documentation may result in the inability to assign a code, or the assigning of an incorrect code. ICD-10-PCS does not have an unspecified code option. Documentation describing a procedure must support the assignment of each character composing the applicable seven-character PCS code. A PCS code is not complete without all seven characters specified.
This Practice Brief provides guidance and solutions for managing an ICD-10-PCS query process that ensures complete provider documentation for accurate coding and reporting. The direction provided herein augments previous AHIMA guidance and includes advice specific to ICD-10-PCS queries. All professionals are strongly encouraged to adhere to these query guidelines regardless of their credential, role, title, or use of any technological tools involved in the query process.
When and When Not to Query
ICD-10-PCS requires a great degree of specificity and granularity. Anyone who assigns codes must use the ICD-10-PCS coding conventions, the Centers for Medicare and Medicaid Services’ (CMS) ICD-10-PCS Official Guidelines for Coding and Reporting, and the American Hospital Association’s (AHA) Coding Clinic for ICD-10-CM and ICD-10-PCS as authoritative sources for the accurate assignment of ICD-10-PCS codes. The introduction to the ICD-10-PCS Official Guidelines for Coding and Reporting includes the following reminder for coding professionals:
A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those procedures that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved.1
As with diagnosis coding, queries may be necessary to obtain complete documentation to support ICD-10-PCS code assignment. The following excerpt from the guidelines, section A8, is essential in determining when to query:
All seven characters must be specified to be a valid code. If the documentation is incomplete for coding purposes, the physician should be queried for the necessary information.2
Not only do the guidelines address when a query may be appropriate, they also clarify expectations regarding a provider’s use of PCS terminology section A11, such as terms associated with root operations:
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.3
In most cases, the information necessary to assign a specific PCS code is included within the provider’s procedure note or operative report. It is the coding professional’s role to translate the provider’s detailed procedural description into PCS definitions through the coding professional’s knowledge of anatomy, PCS character definitions, and guidelines. Generating a PCS query should be considered whenever any character cannot be assigned based on the choices within the applicable PCS table. Examples of when to send a query include:
- The documentation is conflicting, imprecise, incomplete, illegible, ambiguous, invalid, or inconsistent
- The documentation describes a procedure that is inconsistent with clinical tests resulting from the procedure, such as a pathology or cytology report.
- The documentation does not contain information to assign the appropriate root operation (based on the objective of the procedure), body part, approach, device, or other PCS qualifier
- The documentation lacks the necessary laterality
Although open-ended queries are preferred, multiple-choice and “yes/no” queries are also acceptable—and perhaps more appropriate when PCS limits the choices available for code assignment. Unlike diagnosis queries, the “yes/no” query format for PCS does not need to include the additional options associated with multiple-choice queries, which are “other,” “clinically undetermined,” “clinically significant,” and “integral.” These would not be appropriate in a definitive classification system that provides no option to code “undetermined” or “other,” or when all options have been provided.
Guidelines for When and When Not to Write ICD-10-PCS Queries
While deciding when to write an ICD-10-PCS query, it is important to remember:
- Do: Research the official, authoritative resources mentioned in the above section prior to issuing a query.
Example: Per the American Hospital Association (AHA) Coding Clinic ® for ICD-10-CM and ICD-10-PCS Coding, when a catheter tip is documented as ending at the cavoatrial junction, the coding professional may assign the body part character for the superior vena cava without need for physician query.4
- Do not: Query due to a lack of knowledge. The query professional must understand anatomy. Determine the difference between a knowledge deficit and lack of documentation.
Example: Documentation of removal of the sigmoid colon from the descending colon to the rectum would be the removal of the entire body part (Resection). Based on anatomy, it is not necessary to query for partial versus total removal.
- Do not: Query if the body part is specified by the physician but is not specified in PCS.
- Do: Follow the Body Part Key and the coding conventions for branches of body parts (ICD-10-PCS Coding Guideline B4.2).
Example: Documentation states right anterior spinal artery; the PCS Body Part Key translates this anatomical term as “vertebral artery, right.”
- Do: Query if a body part as defined in PCS is not documented.
Example: Physician documents harvesting of the saphenous vein. PCS provides body part characters only for greater saphenous vein or lesser saphenous vein. A query would be necessary to determine the greater or lesser saphenous vein. Coding Clinic guides facilities to work with providers to develop facility-specific coding guidelines, which establish a default code based on common practice at that facility.5 A sample facility policy is seen below in Figure 1.
- Do not: Query when the correlation between specific documentation and the defined PCS term is documented. It is the responsibility of the query professional to make this translation.
Example: Physician documentation states a portion of the duodenum was removed. Do not query for the term “Excision.” The query professional should apply knowledge of PCS definitions and appropriately translate as “Excision.”
- Do: Query if the documentation describes a procedure inconsistent with findings on the pathology report.
Example: The physician’s operative report documents a total removal of the uterus and does not mention the removal of the cervix, and cervix tissue is reflected in the pathology report.
- Do: Query the physician to clarify if the procedure included the removal of the cervix. This will assist in the proper assignment of the 7th character of Supracervical or No Qualifier.
Figure 1: Sample Facility Policy
Purpose: To accurately code Vein Harvesting associated with coronary artery bypass procedures at ABC Medical Center in accordance with ICD-10-CM/PCS Official Coding Guidelines, AHA Coding Clinic, and the Cardiothoracic Surgery Service Line.
Policy: When a patient has a coronary artery bypass graft (CABG), and the physician does not document the specific vein harvested to complete the bypass, it is always coded as the Saphenous Vein UNLESS OTHERWISE STATED by the provider.
This policy may be altered or rescinded as the ICD-10-CM/PCS Official Coding Guidelines and AHA Coding Clinic change in future releases.
How and How Not to Query
A proper query ensures that the documentation in the health record is appropriate and compliant. A compliant query includes clinical evidence to justify why the query was generated as well as proper language. In the creation of a query it is essential that the clinical indicator(s) and evidence are provided to demonstrate proof of the unclear, incomplete, conflicting, and/or ambiguous documentation that lacks support. A PCS query should include specifics to clarify specificity of clinical documentation such as depth of wound debrided. If the pathological findings conflict with what the physician documented in the operative report, query the physician to specify what was excised.
All queries should clearly identify the reason for the query in writing, electronic, or verbal format without leading the provider. If texting is used it should be HIPAA compliant and be tracked as all other queries. When addressing these clinical indicators, it is crucial to understand that a query professional can suspect a certain procedure has been performed based on clinical indicators or evidence but cannot lead the physician to a specific conclusion. If a physician is directed or led to a particular response, it may result in improper coding. A query should not be presumptive, probing, directive, or have any attribute that is leading the provider to a specific response about a procedure. An open-ended or yes or no query format can be used when clarifying laterality or location. A multiple-choice query can be used to clarify the characters of the PCS code such as body part, approach, device, or qualifier.
Another area of importance to consider when determining how to query is being cognizant of the coding language specific to ICD-10-PCS. ICD-10-PCS provides different language options than those utilized by physicians. Many of the terms used to construct ICD-10-PCS codes are defined within the PCS system only, and therefore it is the query professional’s responsibility to determine how the documentation correlates to the PCS definitions. The physician should not be expected to use the same terms used in PCS and a query should not be generated when the correlation between the documentation and the defined PCS terms are clear. For instance, avoid using terms such as “extirpation” or “release” to further clarify documentation of removal of a foreign body, or the lysis of adhesions. The focus should be on accurate and complete documentation in physician language as a best practice.
As another example, if a physician documents a title of the procedure as an “excision of the pancreas,” and it is clear in the operative report documentation that the entire pancreas was removed, a coding professional should code this procedure as “resection of the pancreas” based on PCS root operation definitions. A query is not indicated in this situation.
There may, however, be other times when the documentation is unclear, and the query or coding professional is therefore unable to determine proper coding based on PCS guidelines. It is essential to carefully review the operative report to understand if a physician performed multiple procedures or if different approaches were utilized. When the documentation is unclear, it is necessary to query the physician to determine the accurate code assignment.
Guidelines for How and How Not to Write ICD-10-PCS Queries
When deciding how and how not to query in PCS, it is essential to remember:
- Do not: Lead the physician to a particular outcome that could result in improper coding. A good tip is to focus on asking if the details in the documentation support a more specific or different character value (for example, upper esophagus versus middle esophagus) than what is initially documented, or which may be unclear.
- Do not: Query the provider because clinical documentation is not the same as the PCS terms. Query professionals must be aware of PCS definitions and when definitions are consistent with documentation from a physician a query may not be necessary. The query professional is expected to use their knowledge to apply any correlations.
- Do: Query when documentation is unclear to assign a specific character value based on PCS guidelines (i.e., approaches, multiple sites).
- Do: Query when there is conflicting documentation (i.e., the body of the report states lesser Saphenous vein and the progress notes states greater Saphenous vein).
Queries by Character
Querying for the first two characters of ICD-10-PCS (Section and Body System) seems unnecessary. There are times when a query is necessary for the remaining five characters. Review the coding guidelines for each character for assistance in the development of a query.
Root Operation (Character 3)
It is important to remember that providers are not required to document the specific names of root operations. ICD-10-PCS coding guideline A11 specifically addresses that it is the coder’s responsibility to translate the clinical documentation to the root operations.
If a query is necessary for the root operation, consider the information needed for correct code assignment. Develop the query requesting specific documentation related to the intent of the procedure.
Root Operation Query Example
Clinical Scenario: 65-year-old female admitted with endometrial cancer and subsequently had a total abdominal hysterectomy and a common iliac lymphadenectomy. The operative note states “lymph nodes were removed.”
Compliant Query: This patient had a total abdominal hysterectomy and common iliac lymphadenectomy. The Operative note states “lymph nodes were removed.” Based on your professional judgment can you please further specify if a biopsy was performed or if the intent was to remove all the lymph nodes in this area?
Body Part (Character 4)
The more specific the provider documentation is, the easier it is to assign the correct character for body part. There is no “other” or “unspecified” body part character, so the documentation must clearly define the location of the operation.
Before sending a query to clarify the body part character, the query professional must review the ICD-10-PCS body part guidelines (B4) and understand how to use the Index and/or Body Part Key to assist in identifying the specific body part from the provider documentation. The Body Part Key (which provides a cross-reference for anatomical terms not found in the tables) is an appendix in the manual coding book or is accessible in an encoder software.
Body Part Query Example
Excisional debridement was performed of the necrotic fascia on the left upper leg, and although muscle tissue is identified in the Pathology report, the procedure report did not mention excision of muscle tissue. Based on your professional judgment can you please specify if the debridement include left upper leg muscle?
Approach (Character 5)
The approach character can be difficult to assign as procedures may involve multiple approaches. The provider’s knowledge of each PCS approach available is not expected; therefore, the content of a query should include any reasonable choices for the actual approach. Remember, for a multiple-choice ICD-10-PCS query, the options of “other” or “undetermined” are not necessary.
Approach Query Example
Clinical Scenario: A 35-year-old male was admitted after developing lower abdominal pain and a temperature of 102.2. The admitting diagnosis was appendicitis and he was taken to the OR for a laparoscopic appendectomy. The documentation within the operative note states the procedure performed was an open appendectomy and the body of the operative note states “there was an insertion of a 5 mm blunt port with a 5 mm scope introduction.” The post-op day 1 progress note states s/p open appendectomy with excellent wound healing to the incision.
Compliant Query: The operative note states this was an open appendectomy under the procedures performed, however, there is no documentation of an incision within the body of the operative note and the orders are for a laparoscopic appendectomy. The post-op day 1 progress note states this was an “open appendectomy with good wound healing to the incision.” Based on your professional judgment can the approach used for this procedure be further specified? Please see possible options listed below:
☐ Open appendectomy (if so, please clarify all supporting documentation within the operative note)
☐ Laparoscopic appendectomy (if so, please clarify all supporting documentation within the operative note)
☐ Laparoscopic appendectomy converted to an open appendectomy (if so, please clarify all supporting documentation within the operative note)
☐ Appendectomy performed with endoscope via natural or artificial opening (if so, please clarify all supporting documentation within the operative note)
Device (Character 6)
Querying for the device character will generally involve inquiring whether the device was left in place at the conclusion of the procedure, or a request for more specificity about the device and/or where it was placed in the body. If the physician documents the device brand, check the ICD-10-PCS Device Key to map the specific device brand to the device type in PCS before sending a query. The Device Key is an appendix in the manual coding book or available in an encoder. The device character “Other Device” is the Not Otherwise Specified (NOS) option for the device in ICD-10-PCS, but this option is not found in every PCS table, so a query may be necessary to identify the specific type of device. The electronic health record may also provide documentation in the operating room section such as a sticker from the device or a registration form.
Device Query Example
The patient was taken to the operating room on 2/1/19 for a right total cemented hip replacement. Based on your professional judgment, can you further specify the type of hip replacement hardware used during this procedure:
☐ Ceramic on polyethylene
☐ Metal on polyethylene
☐ Other specified (i.e., brand/product name) ___________________
Qualifier (Character 7)
A query for character seven, qualifier, is going to be very specific depending on the case. Be sure to carefully review the PCS table to identify the qualifier characters available for the procedure coded.
Qualifier Query Example
The patient was admitted with distended abdomen and shortness of breath. Upon admission, the patient underwent abdominal drainage of 30 cc of abdominal fluid.
Based on your professional judgment, can you further specify whether this drainage was diagnostic and/or therapeutic:
☐ Diagnostic drainage
☐ Therapeutic drainage
☐ Both diagnostic and therapeutic
Continuing education for providers regarding documentation requirements to support accurate ICD-10-PCS coding is essential for accurate reporting. Another benefit to ongoing education is the possibility of a reduction in the number of queries sent. Educational sessions are great opportunities to build relationships between the coding staff, the CDI team, and the providers. This also gives the providers the chance to share any concerns they have or thoughts on what is or isn’t working well. In addition to determining education topics, necessary sources should be gathered from both internal and external resources.
Potential Internal Education Topics
Organizations should be trending the top procedure queries sent to providers. Data can be used to develop ongoing educational topics. In addition to top queries, focus on procedures that are performed within an organization and/or leading to readmission. Understanding the procedure performed provides valuable information to apply accurate code assignment. Having a physician explain the operative mechanics of new or existing procedures will assist in developing educational opportunities on applicable documentation requirements for the physician.
Potential External Education Topics
External topics can come from a variety of places, such as the AHA’s Coding Clinic publications and CMS’ Official Coding Guidelines publications. It is essential for query professionals to stay current on documentation requirements and share that information with providers.
Education Delivery Methods
- Rounding: Rounding with physicians is an excellent way to provide education specific to each patient. If scheduling doesn’t allow for rounding time, then participating in grand rounds may be a good alternative.
- Staff Meetings: If providers have a regular staff meeting, the CDI team could request 10 minutes to go over hot topics with the group.
- Posters and Flyers: Placing posters and flyers in areas where providers document can be a valuable tool for having information readily available at the time they are documenting.
- Newsletters and Blogs: Providing ongoing newsletters and blogs will afford providers an easy way to learn of the latest documentation requirements.
- Tip Sheets: Tip sheets should be short and concise covering a specific documentation topic, consider printed flyers or pocket cards for quick and easy access, a shared intranet site is an excellent option.
- Collaborative Education: Have surgeons come to a coding/CDI meeting and discuss the most common procedures and/or diagnoses. Utilize actual health records to facilitate discussion amongst the group. Consider scheduling visual learning opportunities for CDI and coding professionals by inviting them to the operating room or interventional radiology suite to view a procedure.
- Physician Advisor: Appoint an individual as the physician advisor. This individual should know the strategic system goals and advocate for inclusion of documentation concepts in these initiatives. Accurate data is central to any quality and efficiency integrity project.
More Query Examples
Additional examples of ICD-10-PCS queries for root operation, body part, approach, device, and qualifier are available above and in Appendix A: ICD-10-PCS Query Examples. A sample facility query policy is also available.
- Centers for Medicare and Medicaid Services. “ICD-10-PCS Official Guidelines for Coding and Reporting.” 2019. www.cms.gov/Medicare/Coding/ICD10/2019-ICD-10-PCS.html.
- American Hospital Association. Coding Clinic® for ICD-10-CM and ICD-10-PCS 2, no. 4 (Fourth Quarter 2015): 28-29.
- American Hospital Association. Coding Clinic® for ICD-10-CM and ICD-10-PCS 1, no. 3 (Third Quarter 2014): 8.
AHIMA. “Clinical Documentation Improvement: ICD-10-CM/PCS Documentation Tips.” http://bok.ahima.org/PdfView?oid=300621.
AHIMA. “Guidelines for Achieving a Compliant Query Practice (2019 Update).” http://bok.ahima.org/doc?oid=302674#.XIqabPZFyUk.
Appendix A: ICD-10-PCS Query Examples
Body Part Query Example
Based on your professional judgement, can you please further specify if the lysis of adhesions involved the duodenum, jejunum, and/or ileum?
Procedure: Radical debulking of metastatic ovarian cancer
Op Note: “Extensive adhesions of the small intestine were encountered which took considerable time to release."
Thank you in advance for your time.
Lysis of adhesions included the:
☐ Other (please specify)
☐ Unable to determine
Body Part Query Example
Clinical Scenario: A 26-year-old male with a history of continuous smoking since 16 years of age has noted increased shortness of breath, malaise, and fatigue with decreased appetite and weight loss. He is admitted for excision of a lung mass in the right upper lobe.
Compliant Query: The pathology report notes an entire right upper lobe, but the operative report notes the excision of a 1.5 cm mass. Based on your professional judgement can you please clarify this conflicting documentation regarding removal of the entire lobe of the lung vs. an excision of a lesion on the lobe?
Device Query Example
Clinical Scenario: A 45-year-old male began experiencing dull chest pain and was brought to the emergency department and diagnosed with an acute inferior myocardial infarction. A PTCA was performed for treatment of 70 percent stenosis of the distal right coronary artery. A stent was placed in the mid right coronary artery.
Compliant Query: A PTCA was performed for treatment of 70 percent stenosis of the distal right coronary artery with stent placement in the mid right coronary artery. Based on your professional judgment can you please specify the type of stent placed in this procedure?
Prepared By (2019 Update)
Robin Andrews, M.Ed., RHIA, CCS
Patricia Buttner, MBA/HCM, RHIA, CDIP, CHDA, CPHI, CCS, CICA
Laurine Johnson, MS, RHIA, FAHIMA
Katherine Kozlowski, RHIA, CDIP, CCS
Azia Powell, MSHIA, RHIA, CCS
Kimberly Seery, RHIT, CHDA, CDIP, CCS, CPC, CRC
Sandra Bundenthal, RHIA, CCS
Donna Rugg, RHIT, CDIP, CCS, CCS-P
Teresa Smithrud, MA, RHIT, CHPS
Prepared By (Original)
Tammy Combs, RN, MSN, CDIP, CCS, CCDS
Kathryn DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA
Sharon Easterling, MHA, RHIA, CDIP, CCS, CPHM, FAHIMA
Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA
Crystal Isom, RHIA, CCS
Tedi Lojewski, RHIA, CCS, CHDA
Cortnie Simmons, MHA, RHIA, CDIP, CCS
Beth Wolf, MD, CCDS
Danita Arrowood, RHIT, CCS, CCDS
Deanna Banet, RN, BSN, CDIP
Maria Barbetta, RHIA
Sue Bowman, MJ, RHIA, CCS, FAHIMA
Patricia Buttner, RHIA, CDIP, CHDA, CCS
Angie Comfort, RHIA, CDIP, CCS
Kaye Connor, RHIA, CHC
Carl W. Costa, RHIT, CDIP, CHTS-TR, CPC
Suzanne Drake, RHIT, CCS
Cheryl Ericson, RN, MS, CDIP, CCDS
Gail Garrett, RHIT
James S. Kennedy, MD, CDIP, CCS
Daniel Land, RHIA, CCS
Tammy Love, RHIA, CCS, CDIP
Lori McDonald, RHIT, CCS-P
Cindy C. Parman, CPC, CPC-H, RCC
Susan Perkins, RHIT, CCS, CHTS-IM, CHC
Mari Pirie-St. Pierre, RHIA
Donna Rugg, RHIT, CDIP, CCS
Diane Skelton, RHIT, CTR
Geraldine Slawek, RHIT, BHS, CPC, CEDC, CPC-I
Donna D. Wilson, RHIA, CCS, CCDS
Article citation: Combs, Tammy et al. “Guidelines for Achieving a Compliant ICD-10-PCS Query (2019 Update).”AHIMA HIM Body of Knowledge. June 2019.