As more hospitals undertake dual coding in advance of ICD-10, evidence is emerging that suggests clinical documentation may not be the only weak link in the transition. Many are discovering that coders are struggling with the correct selection of the 31 PCS root operations. Dual coding programs are highlighting for many facilities the significant need for advanced PCS training, especially in cardiovascular, muscular skeletal, and obstetrics. A recent pilot undertaken by Amphion revealed more than half of the surgical procedure code errors were attributed to the incorrect selection of the “root operation.” By Minnette Terlep, BS, RHIT, VP of business development and chief compliance officer, Amphion Medical Solutions
By Minnette Terlep, BS, RHIT, VP of business development and chief compliance officer, Amphion Medical Solutions
As more hospitals undertake dual coding in advance of ICD-10, evidence is emerging that suggests clinical documentation may not be the only weak link in the transition. Many are discovering that coders are struggling with the correct selection of the 31 PCS root operations.
Dual coding programs are highlighting for many facilities the significant need for advanced PCS training, especially in cardiovascular, muscular skeletal, and obstetrics. A recent pilot undertaken by Amphion revealed more than half of the surgical procedure code errors were attributed to the incorrect selection of the “root operation.”
Unwanted Exposure
When a root operation error occurs, it results in additional errors throughout the remainder of the codes because the tables used to select the remaining four characters (body part, approach, device, and qualifier) vary depending on the root operation chosen. These errors can result in over- or under-coding and incorrect reimbursements, impacting the bottom line, and potentially exposing the facility to paybacks and penalties under the Centers for Medicare and Medicaid Services’ (CMS) Recovery Audit Contractor (RAC) Program and audits by the Office of the Inspector General (OIG).
In most cases, PCS root operation errors stem from a lack of understanding of the intent of the procedure by the coder. For example, a coder receives the chart of a patient who suffered a posterior dislocation of the right hip and was admitted for reduction. After reviewing the record, the coder must choose between two root operations:
- repair, which is restoring to the extent possible, a body part to its normal anatomic structure and function
- reposition, which is moving to its normal location or other suitable location all or a portion of a body part
If the coder incorrectly selects the “repair” root operation, it will result in the assignment of MS-DRG 482 Hip and femur procedures w/o CC/MCC, with an estimated reimbursement of $9,340.18. If the coder correctly selects “reposition,” the DRG assignment would be MS-DRG 538 Sprains, strains, & dislocation of hip, pelvis, and thigh w/o CC/MCC, with an estimated reimbursement of $4,338.62.
Incorrectly selecting “repair” in this case would have resulted in an over-payment of $5,001.46.
The chance this type of inappropriate reimbursement will go unnoticed by regulators is slim. After finding millions of dollars in overpayments for short inpatient stays in previous examinations, the OIG included in its 2015 Work Plan the intent to dedicate time and resources to study billing variances from 2014. It will also focus on outlier payment data to determine whether necessary reconciliations were performed in a timely manner.
Establishing Intent
The challenge with PCS root operations is that all 31 have distinct definitions that must be matched to the intent of the procedure. To do so, coders must review and comprehend the full procedure report, a process complicated by physicians’ use of terminology that doesn’t neatly match root operation names.
Thus, for maximum effectiveness, dual coding programs must be designed to provide coders with experience in reviewing the intent of the procedure by focusing on the full operative report versus just the name. It’s a significant change from ICD-9, but is an important one as intent ultimately drives PCS code assignment. It means the difference between a coder capable of distinguishing the difference in definitions and locking down the correct root operation and a coder who consistently gets it wrong. It is easy to unknowingly under-code and leave revenue on the table, but it is also easy to up-code by selecting the incorrect root operation, resulting in the facility receiving more reimbursement than it should.
A coder with advanced PCS training and valid hands-on experience through dual coding will know to identify the intent of a procedure and how to break it down to ascertain the proper root operation.
Taking an example from the AHIMA ICD-10-PCS Coder Training Manual, a needle arthrocentesis was performed on the right knee of a patient being evaluated for septic arthritis of the right knee. During the procedure, 15 cc of fluid is removed. The first question a coder must ask is, “What is the intent of the procedure?”
In this case, the intent is arthrocentesis. Breaking down the word reveals that “artho” means joint and “centesis” means puncture. So “arthrocentesis” is the removal of fluid from a joint using a syringe. Knowing the intent leads to the root operation – drainage – defined as the taking out (or removal) of fluids from within a body part. The next question to ask is where the drainage occurred. In this case, it was taken from the right knee joint, a body part in the lower joints body system.
The key is to understand how selection of incorrect root operation can affect the characters that follow. A dual coding program designed to provide hands-on practice in PCS coding after advanced training will ensure coders are prepared to maximize the benefits of ICD-10 out of the gate.
About the author
Minnette Terlep, BS, RHIT, is vice president of business development and chief compliance officer for Amphion Medical Solutions. She can be reached at Minnette.Terlep@amphionmedical.com.
