Health Information Management

Coding for musculoskeletal procedures in ICD-10-PCS

JustCoding News: Inpatient, April 25, 2012

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In ICD-10-PCS, each character has its own meaning, which will make it easier for coders to assign a very specific code. Unfortunately, ICD-10-PCS is not very comparable to the current ICD-9-CM volume 3 codes inpatient coders currently use.

But don’t despair. “[ICD-10-PCS] will be a lot of fun for us once we get into it,” says Sandy Nicholson, MA, RHIA, vice president of Health Information Services for DCBA, Inc. in Atlanta.

Coders familiar with ICD-9-CM volume 3 codes are accustomed to looking in the index to find a code. ICD-10-PCS codes are constructed based on the physician documentation and the procedure the physician performed, says Jennifer Avery, CCS, CPC-H, CPC, CPC-I, senior regulatory specialist with HCPro, Inc., in Danvers, Mass.

“Don’t be nervous about it,” Avery says. “Just jump right in.” Most coders won’t actually have to construct a code themselves because they can use an encoder, she adds. However, most of the certification exams require coders to use a manual.

The meaning of the seven characters changes between the different ICD-10-PCS sections, so let’s focus on the medical and surgical section and procedures performed on the musculoskeletal system.

Characters 1–3

Coders will use the section to determine the first character of the ICD-10-PCS code. ICD-10-PCS includes 16 sections and the first character can be a number or a letter. ICD-10-PCS does not use the letters “I” and “O” to avoid confusion with numbers 0 and 1, says Avery. For example, all codes for procedures start with the number 0.

In the musculoskeletal section, the second character represents the body system and coders can choose from 31 different body systems. Some of the body systems are very specific. For example, 3 represents upper arteries and Q represents lower bones. Others—specifically X and Y—refer to anatomical regions and are less specific, Nichols says.

The third character in an ICD-10-PCS musculoskeletal code represents the root operation. Coders have 31 choices for root operations. “This is a very important piece,” Nichols says. Coders need to learn the definitions of the root operations because physicians are not required to document the specific root operation. According to the 2012 ICD-10-PCS Coding Guidelines, specifically guideline A11:

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.

Nichols says she has never seen a physician actually document an extirpation (taking or cutting out solid matter or material from a body part), but physicians commonly perform this type of procedure. Think thrombectomy, removal of foreign body, choledocholithotomy, and removal of calculus. Look at the definition of the actual procedure being performed to help choose the correct root operation, Nichols recommends.

Also be sure to read the body of the operative report to see what the physician actually did, says Robert S. Gold, MD, CEO and cofounder of DCBA, Inc. Many times what physicians document in the operative note is not what they actually did.

For example, a physician may document an open reduction, internal fixation in the summary. However, when the coder reads the complete operative report, the coder find the physician actually performed a closed reduction then made the incision for the internal fixation.

In this case, coders would report a closed reduction with internal fixation instead of the open reduction. Many times the physician does not perform a reduction if the fragment is aligned well, Gold says. “Read the operative report to see what the physician really did.”

Characters 4–7

In the musculoskeletal system, ICD-10-PCS character four represents the specific body part, such as abdominal aorta, right vocal cord, or left upper arm muscle. Character five denotes the approach—open, percutaneous, percutaneous endoscopic, and so on.

The sixth character represents a device and coders need to rethink devices in ICD-10-PCS. Coders only report devices that remain in the body, Nichols says. That includes rods, pins, plates, and prostheses. A temporary catheter is not considered a device in ICD-10-PCS.

The seventh character is the qualifier and it has an extremely narrow application and may only pertain to certain body systems, Nichols says. For many ICD-10-PCS codes in the musculoskeletal section, coders will report Z (no qualifier) as the seventh character. Because of its limited application, the qualifier does not have specific guidelines on when to use it. If a qualifier exists, coders need to report it, Nichols says.

Coding femur fracture procedures

Coders may often see a fracture of the femur. Coders will need to know where specifically the patient’s femur is fractured in order to select the appropriate code. Examples of femur fracture locations include:

  • Femoral head
  • Femoral neck
  • Greater trochanter
  • Intertrocanteric area
  • Lesser trochanter
  • Femoral shaft, also known as the diaphysis
  • Supracondylar area

Let’s look at how to code for internal fixation of a fracture of the right femoral neck. The codes for an open reduction and a closed reduction are almost identical. Only the approach (character five) is different. For an actual open reduction with internal fixation, coders would report 0QS604Z, while for a closed reduction with internal fixation, they would report 0QS634Z.

The first character, 0, represents the medical and surgical section, while the second character, Q, represents the long bones. If a different bone is involved, coders would choose a different second character. The third character, S, represents the root operation. In this scenario, the physician is moving all or a portion of a body part to its normal location, so it is root operation Reposition.

The fourth character denotes the specific body part. So the number 6 represents the right upper femur. Other possible body parts include, but are not limited to:

  • 7, Upper femur, left
  • 8, Femoral shaft, right
  • 9, Femoral shaft, left
  • B, Lower femur, right
  • C, Lower femur, left
  • G, Tibia, right
  • H, Tibia, left
  • J, Fibula, right
  • K, Fibula, left

A fifth character of 0 denotes the open approach, while the number 3 represents a percutaneous approach. If the physician used a percutaneous endoscopic approach, coders would report the number 4. Note that only those three approaches are appropriate for this code. Coders may have other approach choices for different procedures.

Because the physician documented internal fixation, coders would use the number 4 as the sixth character. If the physician used external fixation, coders would chose one of the following sixth characters:

  • 5, External fixation device
  • B, External fixation device, monoplanar
  • C, External fixation device, ring
  • D, External fixation device, hybrid

If the physician did not use a device, coders would report Z as the seventh character. The seventh character will always be Z for this operation because no other character is available.

Coding rotator cuff repairs

Let’s look at another procedure in the medical and surgical section, this time a rotator cuff repair. Three shoulder muscle tendons make up the rotator cuff:

  • Long head of the biceps
  • Subscapularis
  • Infraspinatus

Tears usually occur from lateral to medial, meaning the long head of the biceps generally tears first then the subscapularis, and finally the infrapinatus, Gold says. A partial tear of the rotator cuff involves either the long head of the biceps only or the long head of the biceps and the subscapularus. A complete tear involves all three tendons.

Surgeons can perform a rotator cuff repair as an open procedure or arthroscopically by suturing the tendons back into place.

For an open repair of a left rotator cuff tear, coders would report 0LQ20ZZ. The first character 0 represents the medical and surgical section. The second character L denotes tendons. The root operation Q tells us this is a repair. The body part 2 specifies left shoulder tendon, while the approach 0 designates an open approach. The final two characters are both Z, meaning no device is left in place and no qualifier applies.

If the right shoulder tendons are involved, coders would use 1 for the body part. Other specific tendons include, but are not limited to:

  • 0, Head and neck tendon
  • 3, Upper arm tendon, right
  • 4, Upper arm tendon, left
  • 7, Hand tendon, right
  • 8, Hand tendon, left
  • 9, Trunk tendon, right
  • B, Trunk tendon, left
  • C, Thorax tendon, right
  • D, Thorax tendon, left
  • J, Hip tendon, light
  • K, Hip tendon, left

For the approach, physicians can use open (0), percutaneous (3), or percutaneous endoscopic (4). The physician needs to document the specific approach in the medical record.

Email your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at

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