Module 04 Assignment - ICD-10-PCS Coding Principles and Code Build Process
Overview: There are 3 parts to this assignment. Each part of the assignment addresses a specific aspect of ICD-10-PCS coding. To code accurately
using the ICS-10-PCS system requires the ability to understand and apply the coding principles to clinical documentation by following the
designated code build process.
Part A: ICD-10-PCS Identify Coding Guidelines
The ICD-10-PCS system includes specific conventions and coding guidelines or “rules” which provide instruction on how to accurately construct
the codes. This portion of the assignment will provide an opportunity to become more familiar with the guidelines to be used in the
determination of the appropriate PCS code.
Instructions: Utilize the ICD-10-PCS Official Coding Guidelines presented in the front of the ICD-10-PCS Code Book to match the narrative in the
assignment for Part A.
Steps:
For each coding guideline narrative,
1. Read the narrative in Column 1-Part A in the table below.
2. Match the coding guideline(s) narratives in Column 1-Part A with the Official Coding Guidelines found in the front of the ICD-10-
PCS Code Book.
3. Enter the alphanumeric label identifier from the Official Coding Conventions/Guideline(s) in Column 2-Part A of the table in
correlation to the coding guideline narrative in Column 1-Part A. If there is more than one applicable Coding Convention or Guideline
for the narrative, enter both guideline labels in Column 2-Part A corresponding to the narrative in Column 1-Part A.
4. Reference both A and B conventions and guidelines from The Official Coding Guidelines in the front of the ICD-10-PCS Code Book.
Table for Part A - Identify the Official Coding Guideline
Column 1-Part A Column 2-Part A
ICD-10-PCS Coding
Guideline
Coding Guidelines
Identifiers
Example: A1
ICD-10-PCS codes are always composed of 7 characters.
Page 1 of 8
, 1A. It is not required that the provider document using the exact PCS terms. The coder has the responsibility to A1
correlate the clinical documentation stated by the provider to the correct Root Operation definition without
querying the provider for clarification.
2A. The Code Tables in the code book may be accessed directly or the Alphabetic Index may be used to locate the A6
correct table. It is optional to use the Alphabetic Index, but the PCS Code Tables must always be consulted to
determine a valid code.
3A. Each of the 7 characters of a PCS codes has a specific “value”. The character can be represented by a number
value of 0 – 9 or an alphabetic letter value with the exception of alpha characters O and I to avoid confusion with 0
(zero) and 1 (one). Use of and O or I in a PCS code results in an invalid code.
4A. For a PCS code to be valid, the combinations of the 4th – 7th character values must all be obtained from the A9
same row in the PCS Code Tables.
5A. Components of a procedure that are stated in the Root Operation definition and explanation are NOT coded B3.1b
separately. Also, any procedural steps necessary to reach the operative site and close the operative site, including
anastomosis of a tubular body part, are NOT coded separately.
6A. Multiple procedures are coded if during the same operative encounter, the same root operation is performed B3.2a
on different body parts as defined by distinct values of the body part character.
7A. If a procedure is performed on a portion of a body part that does not have a separate body part value, code the B4.3
body part value corresponding to the whole-body part.
8A. The Root Operations Excision, Extraction and Drainage are used for Biopsy procedures along with the Qualifier B3.4a
X-Diagnostic. The X Qualifier is only used for procedures such as biopsies, where the intent of the procedure is to
remove a portion of the body part for the purpose of analysis. Documentation that merely states the specimen
was sent to Pathology does NOT equate to a diagnostic intent as this is a standard procedure for all removed
tissue.
Page 2 of 8
Overview: There are 3 parts to this assignment. Each part of the assignment addresses a specific aspect of ICD-10-PCS coding. To code accurately
using the ICS-10-PCS system requires the ability to understand and apply the coding principles to clinical documentation by following the
designated code build process.
Part A: ICD-10-PCS Identify Coding Guidelines
The ICD-10-PCS system includes specific conventions and coding guidelines or “rules” which provide instruction on how to accurately construct
the codes. This portion of the assignment will provide an opportunity to become more familiar with the guidelines to be used in the
determination of the appropriate PCS code.
Instructions: Utilize the ICD-10-PCS Official Coding Guidelines presented in the front of the ICD-10-PCS Code Book to match the narrative in the
assignment for Part A.
Steps:
For each coding guideline narrative,
1. Read the narrative in Column 1-Part A in the table below.
2. Match the coding guideline(s) narratives in Column 1-Part A with the Official Coding Guidelines found in the front of the ICD-10-
PCS Code Book.
3. Enter the alphanumeric label identifier from the Official Coding Conventions/Guideline(s) in Column 2-Part A of the table in
correlation to the coding guideline narrative in Column 1-Part A. If there is more than one applicable Coding Convention or Guideline
for the narrative, enter both guideline labels in Column 2-Part A corresponding to the narrative in Column 1-Part A.
4. Reference both A and B conventions and guidelines from The Official Coding Guidelines in the front of the ICD-10-PCS Code Book.
Table for Part A - Identify the Official Coding Guideline
Column 1-Part A Column 2-Part A
ICD-10-PCS Coding
Guideline
Coding Guidelines
Identifiers
Example: A1
ICD-10-PCS codes are always composed of 7 characters.
Page 1 of 8
, 1A. It is not required that the provider document using the exact PCS terms. The coder has the responsibility to A1
correlate the clinical documentation stated by the provider to the correct Root Operation definition without
querying the provider for clarification.
2A. The Code Tables in the code book may be accessed directly or the Alphabetic Index may be used to locate the A6
correct table. It is optional to use the Alphabetic Index, but the PCS Code Tables must always be consulted to
determine a valid code.
3A. Each of the 7 characters of a PCS codes has a specific “value”. The character can be represented by a number
value of 0 – 9 or an alphabetic letter value with the exception of alpha characters O and I to avoid confusion with 0
(zero) and 1 (one). Use of and O or I in a PCS code results in an invalid code.
4A. For a PCS code to be valid, the combinations of the 4th – 7th character values must all be obtained from the A9
same row in the PCS Code Tables.
5A. Components of a procedure that are stated in the Root Operation definition and explanation are NOT coded B3.1b
separately. Also, any procedural steps necessary to reach the operative site and close the operative site, including
anastomosis of a tubular body part, are NOT coded separately.
6A. Multiple procedures are coded if during the same operative encounter, the same root operation is performed B3.2a
on different body parts as defined by distinct values of the body part character.
7A. If a procedure is performed on a portion of a body part that does not have a separate body part value, code the B4.3
body part value corresponding to the whole-body part.
8A. The Root Operations Excision, Extraction and Drainage are used for Biopsy procedures along with the Qualifier B3.4a
X-Diagnostic. The X Qualifier is only used for procedures such as biopsies, where the intent of the procedure is to
remove a portion of the body part for the purpose of analysis. Documentation that merely states the specimen
was sent to Pathology does NOT equate to a diagnostic intent as this is a standard procedure for all removed
tissue.
Page 2 of 8
