Health Information Management

Select your ICD-10-PCS principal procedure

HIM-HIPAA Insider, June 10, 2013

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Sometimes our patients are very sick, very injured, or undergo multiple procedures during their stay. So how do you pick your principal procedure code in ICD-10-PCS?

The ICD-10-PCS guidelines offer the following information to use when determining the principal procedure in different situations:

  • Procedure performed for definitive treatment of both principal diagnosis and secondary diagnosis. Sequence the procedure performed for definitive treatment most related to principal diagnosis as principal procedure.
  • Procedure performed for definitive treatment and diagnostic procedures performed for both principal diagnosis and secondary diagnosis. Again we are going to sequence the procedure performed for definitive treatment most related to principal diagnosis as principal procedure.
  • A diagnostic procedure was performed for the principal diagnosis and a procedure is performed for definitive treatment of a secondary diagnosis. Sequence the diagnostic procedure as the principal procedure, since the procedure most related to the principal diagnosis takes precedence.
  • No procedures performed that are related to principal diagnosis; procedures performed for definitive treatment and diagnostic procedures were performed for secondary diagnosis. Sequence procedure performed for definitive treatment of secondary diagnosis as principal procedure, since there are no procedures (definitive or nondefinitive treatment) related to principal diagnosis.

When you look at the guidelines, they’re not really different from what we currently do. We’re always going to list the procedure most related to the principal diagnosis first. The only time you wouldn’t is when the physician doesn’t perform a procedure related to the principal diagnosis.

That makes sense when you remember that the principal diagnosis is the main reason the patient came in. So we’re going to treat the main problem first, then deal with any procedures for secondary diagnoses.

This article originally appeared on HCPro, Inc.’s ICD-10 Trainer blog.



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