ICD-10 PCS: Harnessing the Power of Procedure Codes

When the U.S. healthcare system transitioned from ICD-9 to ICD-10 codes in 2015, the number of available PCS (Procedure Coding System, a U.S. classification system referring to procedures in an inpatient setting) codes jumped from roughly 3,000 to more than 70,000. This drastic increase means clinicians can code procedures with a much higher degree of specificity. In addition, ICD-10-CM diagnosis codes increased from 13,000 to 68,000.

虽然向ICD-10的转变要求医疗组织改变医疗遭遇的记录方式，但这样做使组织能够利用ICD-10程序代码背后的强大分析。有了对如何提供住院程序性护理的新见解，卫生系统可以改善患者的结果和价值。

Building Procedural Integration Hierarchies for Analytic Insights

Health Catalyst uses a Clinical Integration Hierarchy, which allows for more precise analysis of the care provided—and thus more actionable data for clinicians or administrators to review.

The Clinical Integration Hierarchy heavily utilizes ICD diagnosis codes to organize and analyze data according to care processes. This hierarchy groups healthcare into work processes that reflect how care is actually delivered, across departments and care settings, and provides a relevant, focused structure for prioritizing and implementing improvement initiatives. By organizing and analyzing data according to care processes, health systems can determine which of these processes offer the greatest opportunity for improving quality and reducing unnecessary cost.

Similarly, Health Catalyst is now building a Procedural Integration Hierarchy utilizing procedure-based code. This allows healthcare organizations the ability to glean important analytics insights using procedure data as well as leveraging the higher degree of specificity that ICD-10 allows. The addition of a procedural integration hierarchy will complement the clinical integration hierarchy and allow clinicians and hospital leaders more contextual information.

For instance, health systems are currently unable to identify by diagnosis codes if transplant patients had the transplant on their current encounter, or if the admission was related to underlying management of their medical condition. This is crucial information when looking at variation in costs, length of stay (LOS), and/or rates for readmission. There’s the potential for significant variation in surgical costs and medical management from one patient to the next by simply looking at diagnosis codes. Similarly, when looking at procedure codes, three different patients may have had a portion of their colon removed for varying reasons (e.g., a gun shot, colorectal cancer, severe irritable bowel syndrome [IBS], etc.). All three patients would show as having colectomies but the length of LOS, processes, and outcomes could be intentionally different. Neither coding tool provides a full picture, as it captures single variables when classifying a patient stay; the procedural hierarchy will help add content and context to the data available. The ICD-10 system is structured for an analytics platform, such as the Health Catalyst® Data Operating System (DOS™), to harness information about a health system’s patients.

Benefits of ICD-10 Procedure Codes

The International Classification of Diseases (ICD) was initially developed and published by theWorld Health Organization (WHO)使全球医疗报告标准化。According to the WHO, “ICD is the foundation for the identification of health trends and statistics globally, and the international standard for reporting diseases and health conditions.” Many revisions of ICD have been made and ICD-9 was not expansive enough for future healthcare needs with its limited number of codes and outdated information.

Even though the transition to ICD-10 in 2015 disrupted the healthcare industry, the potential analyticbenefitslikely outweighed the disruption:

• Specificity– Allows for higher degree of specificity with codes composed of seven alphanumeric characters (as opposed to three to five numerals with a decimal point in ICD-9). ICD-10 precisely defines procedures with detail regarding body part, approach, medical devices used, and other qualifying information.
• Scalable-该结构被设计为可扩展的新程序添加或新技术的发挥。
• Standardized Terminology– Provides precise and stable definitions of all procedures performed and reflects current usage of medical terminology and devices.

Specificity

The structure of the ICD-10 PCS system is designed in a way that has the potential to drive powerful analytic insights. Each character can be one of any 34 possible values (numbers 0-9, and letters A-Z, excluding letters O and I to avoid confusion with numbers zero and one). Additionally, characters have a hierarchical relationship and the same character placed in a different position has a different meaning (Figure 1).

The following example identifies the meaning of each character of the code:

Right knee joint replacement = 0SRD0JZ

0 = Medical and Surgical Section
S = Lower Joints
R = Replacement
D = Knee Joint, Right
0 = Open
J = Synthetic Substitute
Z = No Qualifier

Precision and Laterality

Going hand in hand with specificity, ICD-10 procedure codes precisely define procedures with detail regarding body part, approach, medical devices used, and other qualifying information. The addition of laterality, such as right-knee replacement vs. left-knee replacement can add additional clinical insights to data.

此外，每个字符的定义是其在代码中的物理位置的函数。例如，程序代码的第5个字符表示方法类型，因此医院管理员可以仅使用第5个字符查看开放式手术的总数量或微创手术的总数量。添加第七个字符后，管理员可以查看整个系统对特定身体部位进行的活组织检查的总数。这些例子有助于突出使用过程代码进行分析的强大的特异性级别。

Scalable

ICD-9程序代码只包含3到5个数字字符，限制了添加新代码的空间。ICD-10 PCS的设计具有随着新程序的增加或新技术的应用而增加新代码的灵活性。

Standardized Terminology

With the release of ICD-10 procedure codes, CMS standardized the definitions of all procedure codes. ICD-10 PCS provides precise and stable definitions of all procedures performed where ICD-9 procedure codes were based on outdated technology and lacked current, accepted definitions. While this standardization is in many ways a benefit of ICD-10 PCS, there are also some drawbacks.

Drawbacks of ICD-10 Procedure Codes

Drawbacks include the following:

• ICD-10 PCS是美国专用的(英国和加拿大都没有使用)。
• ICD-10 does not includeeponyms，常用程序名称、术语或首字母缩写。
• It can be necessary to look at secondary procedure codes in order to correctly identify the type of surgery performed.

程序规范的标准化带来了稳定性，消除了过时的术语，但也造成了上述限制。A good example is the elimination of eponyms, which resulted in the elimination of some well-known procedures like theWhipple, defined by theMayo Clinic作为“切除胰头、小肠(十二指肠)的第一部分、胆囊和胆管的手术”。对于ICD-9, Whipple被编码为根治性胰十二指肠切除术，更广为人知的是52.7。With ICD-10 PCS, the Whipple procedure is now often defined by the use of the following seven unique procedure codes:

• Excision of pancreas, open approach (0FBG0ZZ).
• Resection of duodenum, open approach (0DT90ZZ).
• Resection of gallbladder, open approach (0FT40ZZ).
• Excision of common bile duct, open approach (0FB90ZZ).
• Bypass of common bile duct to small intestine, open approach (0F190ZB).
• 胃切除术，开腹入路(0DB60ZZ)。
• Resection of stomach, pylorus, open approach (0DT70ZZ).

Similarly, ICD-10 PCS does not include common procedure names, terms or acronyms, such as appendectomy, coronary artery bypass grafting (CABG), or total knee arthroplasty (TKA).

As a result of increased specificity, with some complex procedures or multiple step surgeries, it can be difficult to determine what procedure was performed by looking just at the primary procedure code. In many cases, it may be necessary to look at secondary procedure codes in relationship to the entire procedure in order to correctly identify the type of surgery that was performed. A good example of this is with a total knee replacement. A total knee revision is often coded the same as the initial replacement, with the addition of a secondary procedure code. For example:

• Total knee replacement:
  • Primary Procedure Code: Replacement of right knee joint with synthetic substitute, cemented, open approach (0SRC0J9).
• Total Knee Revision:
  • Primary Procedure Code: Replacement of right knee joint with synthetic substitute, cemented, open approach (0SRC0J9)
  • Secondary Procedure Code: Removal of synthetic substitute from right knee joint, open approach (0SPCOJZ)

With ICD-10, there can be multiple procedure codes to document and analyze. In the case of the knee replacement above, if someone looked at only the primary procedure code, he could easily misclassify the procedure. Between the two procedures–total knee replacement and total knee revision–there would be intended variation between the two procedures such as time metrics in the operating room, difference in length of stays, readmission rates, or even cost case events. All of this intended variation would be inaccurately shown asunintended variationif only looking at the primary procedure code.

Procedural and Clinical Hierarchy Combine to Give New Insights

世界杯葡萄牙vs加纳即时走地Health Catalyst的临床整合层次结构提供完整的上下文信息，这些信息可能为医疗保健系统带来新的和独特的临床见解。随着程序层次的增加，临床医生和管理人员可以结合出院诊断原则查看程序代码，以了解患者最初住院的原因。或者，他们可以观察哪种类型的外科医生正在进行一种手术，以及与不同类型的外科医生进行相同手术的结果比较。然后可以分享见解，以改善患者的结果，分析可以用来促进这样的对话。

The multitude of scenarios this Procedural Hierarchy can impact are broad. A health system could build clinically defined criteria, based upon current best-practice recommendations, incorporating procedure-based logic that in-turn can correctly identify patients who may benefit from a higher hemoglobin threshold in comparison to a healthy patient with trauma. They could create cohorts within a total joint application to construct population as to the benefits of uncemented vs. cemented arthroplasty. Clinical leaders could examine outcomes when robotic instruments are used vs. when they are not. There is an almost endless amount of possible ways that a healthcare system can use ICD-10 procedure codes to carve, slice, and examine their data. The bottom line from an improvement standpoint is that Health Catalyst is continuously building insights and consolidating data in such a manner that has not previously been available.

As with other development, Health Catalyst is employing a pragmatic approach by using thePareto principlein order to provide the logic for 80 percent of the cases and leaving 20 percent to be customized to the specific needs of a health system or improvement project. And, as the Procedural Integration Hierarchy is being built, developers are creating the ability to pull data directly from the CMS website when changes in procedure codes are released. This is just one example of the benefits of DOS™ Marts–the ability of healthcare systems to rely on experts in a variety of areas, accessing pre-baked content to reduce the workload on analysts so they can focus on ensuring the data is valid and tailoring queries to fit their specific needs.

Just like the Clinical Integration Hierarchy, the Procedural Integration Hierarchy ties back to the three systems approach. The best way to achieve and sustain quality and cost improvement is a systematic approach (the best practice, analytics, and adoption systems). Healthcare organizations must implement all three systems to achieve ongoing success. In addition, the three systems must work together. Health Catalyst is ultimately much more than an analytics solution, but also an access point to experts in a variety of areas who pave the way for all aspects of healthcare improvement.

Additional Reading

Would you like to learn more about this topic? Here are some articles we suggest:

1. Care Management Analytics: Six Ways Data Drives Program Success
2. How to Apply Machine Learning in Healthcare to Reduce Heart Failure Readmissions
3. Prioritizing Healthcare Projects to Optimize ROI

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