Differentiating Procedure Approach in ICD-10-PCS: Fifth Character Captures Specificity

By Ann Barta, MSA, RHIA

One of ICD-10-PCS’s goals is to ensure a complete picture of a patient’s procedure. Completeness means that there is a unique code for all substantially different procedures, including the same procedure performed using a different approach.

All ICD-10-PCS codes are seven characters long, with the fifth character from the medical and surgical section identifying the approach. The approach is defined as the technique used to reach the site of the procedure. Approaches may be through the skin or mucous membrane, through an orifice or external.

ICD-10-PCS describes seven different approaches: open, percutaneous, percutaneous endoscopic, via natural or artificial opening, via natural or artificial opening endoscopic, via natural or artificial opening with percutaneous endoscopic assistance, and external.

Open Approach

An open approach is defined as cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure. Procedures performed via an open approach have a fifth character value of 0. The access location for this approach is through either the skin or a mucous membrane; the type of instrumentation used is not applicable.

The ICD-10-PCS code for a laparotomy with removal of the gallbladder is 0FT40ZZ, with the fifth character of the code (0) indicating that the procedure was performed via an open approach. During this procedure an incision is made through the abdominal wall (laparotomy) to remove the gallbladder.

Another example of an open approach is an abdominal hysterectomy with a Tru-Cut needle biopsy of the left lobe of the liver. During this procedure a Pfannenstiel incision is made, the abdominal cavity is opened and explored, and a needle biopsy is performed. Subsequently the uterus is also removed.

The approach for both of these procedures is open. In this case the laparotomy was the technique used to reach both procedural sites, the liver and the uterus.

ICD-10-PCS Draft Coding Guideline B5.1 states that procedures performed using the open approach with percutaneous endoscopic assistance are coded to the approach value 0, open. Therefore, the value of the fifth character of the code for a laparoscopic-assisted sigmoidectomy is 0.

Percutaneous Approach

A procedure performed via a percutaneous approach (character value 3) is one in which there is 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.

The ICD-10-PCS code for a diagnostic percutaneous paracentesis for ascites is 0W9G3ZX, with the fifth character (3) indicating a percutaneous approach. During this procedure a small incision is made and a needle or catheter is inserted into the peritoneal cavity to obtain ascitic fluid. Another example would be a PTCA of the right coronary artery with the insertion of a stent, which codes to 02703DZ.

Liposuction is another procedure in which the approach to the operative site is percutaneous. During this procedure a small tube-like instrument called a cannula is inserted through tiny incisions to surgically remove fat cells. The code for liposuction, for medical purposes, left upper arm, is 0JDF3ZZ.

ICD-10-PCS Draft Coding Guideline B5.4a states that procedures performed via an indwelling device are coded to approach value 3, percutaneous. Fragmentation of kidney stone performed via percutaneous nephrostomy illustrates the use of this guideline, and the approach value for this procedure is 3.

Percutaneous Endoscopic Approach

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.

Laparoscopy with ablation of endometriosis of the endometrium is performed via a percutaneous endoscopic approach. During this procedure small incisions are made and a laparoscope (visualization instrumentation) is used to reach the site of the procedure. The code for this procedure is 0U5B4ZZ, with the fifth character (4) indicating the approach.

If this procedure was performed via a hysteroscope instead of a laparoscope the correct code would be 0U5B8ZZ, with a fifth character of 8 for via natural or artificial opening endoscopic since the hysteroscope is inserted through the vagina (natural opening).

Via Natural or Artificial Opening Approach

An approach made via either a natural or artificial opening (character value 7) is defined as the 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.

A dilation and curettage (D&C) would be an example of a procedure performed using this approach. During the D&C, the cervix is dilated by inserting instrumentation via the vagina (natural opening). The instrumentation is then used to remove uterine tissue. A D&C performed via this approach is coded to 0UDB7ZZ.

In contrast, a D&C performed with the use of a hysteroscope would be coded to 0UDB8ZZ, as visualization instrumentation (hysteroscope) was used to reach the site of the procedure.

Another example of a procedure performed using a natural or artificial opening is the insertion of a Foley catheter (code 0T9B70Z). The Foley catheter is inserted via the urethra (natural opening) into the bladder.

Via Natural or Artificial Opening Endoscopic Approach

A via natural or artificial opening endoscopic approach (character value 8) is defined as the 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.

An endoscopic retrograde cholangiopancreatography with lithotripsy of the common bile duct (code 0FF98ZZ) is performed via a scope (visualization instrumentation) entering through the mouth (natural opening) for access to the biliary system via the duodenum. Therefore, the approach value is 8.

Another example using this approach is a diagnostic bronchoscopy of the left upper lobe bronchus, which codes to 0BJ88ZZ. During this procedure a bronchoscope (visualization instrumentation) is inserted into either the nose or the mouth (natural opening) and passed into the bronchus.

Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance Approach

An approach made via natural or artificial opening with percutaneous endoscopic assistance (character value F) is defined as the 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.

ICD-10-PCS Draft Coding Guideline B5.2 states that procedures performed via natural or artificial opening with percutaneous endoscopic assistance are coded to approach value F. The code for a laparoscopic-assisted total vaginal hysterectomy is 0UT9FZZ, with the fifth character value of F.

External Approach

The 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.

One example of a procedure performed via an external approach is extracorporeal shock wave lithotripsy of a calculus of the right kidney, which codes to 0TF3XZZ. During this procedure shock waves generated outside the body are used to fragment the renal calculus. Since the body is not entered, the appropriate fifth character value is X.

ICD-10-PCS Draft Coding Guideline B5.3a states that procedures performed within an orifice on structures that are visible without the aid of any instrumentation are coded to approach value X. An example using this guideline would be resection of the tonsils. This procedure would be coded with a fifth character value of X.

ICD-10-PCS Draft Coding Guideline B5.3b indicates that procedures performed indirectly by the application of external force through the intervening body layers are coded to approach value X. Therefore, when coding a closed reduction of a fracture, the fifth character of the code would be X.

Resource

“ICD-10-PCS Draft Coding Guideline.” Appendix B in “ICD-10-PCS Reference Manual.” 2008. Available online at www.cms.hhs.gov/ICD10/Downloads/pcs_refman.pdf.

Ann Barta (ann.barta@ahima.org) is a professional practice resource specialist at AHIMA.