When Reviewing the â€å“constructionã¢â‚¬â of Icd-10-pcs Codes the Fifth Character Defines the

• Journal Listing
• J Thorac Dis
• 5.11(Suppl 4); 2019 Mar
• PMC6465427

J Thorac Dis. 2019 Mar; xi(Suppl 4): S585–S595.

ICD-10-CM/PCS: potential methodologic strengths and challenges for thoracic surgery researchers and reviewers

James Thousand. Clark,^one Garth H. Utter,^{2, 3} Miriam Nuño,⁴ Patrick Due south. Romano,^{v, half-dozen} Lisa G. Brown,^{1, 3, vii} and David T. Cooke ^{1, 3, 7}

James One thousand. Clark

¹Department of Full general Thoracic Surgery, Section of Surgery, University of California, Davis Health, Sacramento, CA, U.s.a.;

Garth H. Utter

²Division of Trauma, Acute Care Surgery and Surgical Critical Care, Department of Surgery, University of California, Davis Health, Sacramento, CA, USA;

³Outcomes Inquiry Group, Section of Surgery, University of California, Davis Health, Sacramento, CA, USA;

Miriam Nuño

⁴Department of Public Health Sciences, Division of Biostatistics, University of California, Davis Health, Sacramento, CA, USA;

Patrick S. Romano

⁵Center for Healthcare Policy and Inquiry, University of California, Davis Health, Sacramento, CA, USA;

⁶Department of Internal Medicine, University of California, Davis Health, Sacramento, CA, United states;

Lisa M. Brown

^aneSection of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA, Us;

^threeOutcomes Inquiry Group, Section of Surgery, University of California, Davis Health, Sacramento, CA, USA;

⁷Thoracic Surgery Outcomes Research Network

David T. Cooke

ⁱSection of General Thoracic Surgery, Department of Surgery, Academy of California, Davis Wellness, Sacramento, CA, United states;

³Outcomes Research Group, Department of Surgery, Academy of California, Davis Health, Sacramento, CA, USA;

⁷Thoracic Surgery Outcomes Inquiry Network

Received 2019 Jan four; Accepted 2019 Jan 17.

Abstruse

The contempo implementation of the International Classification of Diseases, 10^th Revision, Clinical Modification and Procedure Coding Organisation (ICD-x-CM/PCS) provides a robust classification of diagnoses and procedures for hospital systems. As researchers begin using ICD-x-CM/PCS for outcomes enquiry from administrative datasets, it is important to understand ICD-x-CM/PCS, besides as the strengths and challenges of these new classifications. In this review, we describe the development of ICD-10-CM/PCS and summarize how it applies specifically to thoracic surgery patients undergoing pulmonary lobectomy, sublobar resection (segmentectomy or wedge resection) and esophagectomy. This myriad of ICD-10-CM/PCS codes presents challenges and questions for thoracic surgery researchers and medical journal reviewers and editors when evaluating thoracic surgical outcomes research utilizing ICD-ten-CM/PCS. Boosted work is needed to develop consensus guidelines and uniformity for authentic and coherent research methods to utilize ICD-x-CM/PCS in future outcomes enquiry efforts.

Keywords: International Classification of Diseases, clinical coding, thoracic surgical procedures, research design, outcomes research

Groundwork

The International Classification of Diseases, 10^th Revision (ICD-x), is a ready of agreed upon diagnosis codes developed by the Earth Health Organization (WHO) every bit part of its Family unit of International Classifications. This organisation provides a robust coding system for classifying diagnoses and other clinical concepts. The previous iteration, the International Classification of Diseases, 9^th Revision (ICD-nine), was developed past the WHO in 1975. Before long later, the National Center for Wellness Statistics (NCHS) applied the WHO'south organisation to allocate diseases and morbidities in the inpatient hospital setting, creating the ICD-9 Clinical Modification (ICD-ix-CM), comprising approximately 14,000 dissimilar diagnosis codes (i). An boosted nomenclature for procedures (not part of the WHO organisation) was added as Book iii of ICD-ix-CM, comprising approximately 4,000 procedure codes. This system was adopted by almost payers in the United States for managing provider payments, at the bidding of the Health Intendance Financing Administration (HCFA), which required it in documentation of diagnosis and procedures for billing purposes in 1989. The HCFA was renamed to the Centers for Medicare and Medicaid Services (CMS) in 2001, and ICD-nine-CM was adopted as a required code set for covered entities under the Health Insurance Portability and Accountability Deed (HIPAA) transaction standards.

With the ongoing rapid expansion of diagnoses since 1975, the WHO published ICD-ten in 1993. The ICD-10 Clinical Modification (ICD-10-CM), developed by the NCHS in 2002, contains approximately 68,000 diagnosis codes (2). The ICD-10 Procedure Coding Organization (ICD-ten-PCS), built past HCFA and 3M Health Information Systems and initially released in 1998, encompasses well-nigh 73,000 procedure codes (3). After several delays, CMS finally required providers and payers to transition to ICD-10-CM/PCS on October ane^st, 2015, 22 years after the WHO start published the 10^th revision.

ICD-9-CM has been utilized extensively for large database wellness services research studies evaluating thoracic surgical outcomes (4-half dozen). ICD-9-CM, Volume 3, has been used in a number of thoracic surgical issue studies, including those demonstrating positive book-outcome relationships in video-assisted thoracic surgery (VATS) (seven), increasing utilization of VATS over open thoracotomy from 2010–2014 (8), and decreased complication rates and shorter infirmary stays amidst patients undergoing robotically assisted every bit opposed to VATS lobectomy (9). ICD-ix-CM has been an of import tool supporting the utilise of large, readily available authoritative datasets in healthcare quality and surgical outcomes enquiry. With the transition to ICD-x-CM/PCS, it is vital to empathize the changes involved in the code structure, and how these volition affect study design and dataset analysis. Nosotros anticipate that health services research with ICD-10-CM/PCS codes will be challenged in selecting appropriate codes and agreement how those lawmaking choices impact written report methodology, accuracy of results, interpretation of data and the ability to compare studies from different institutions. In that location are currently no big-calibration studies of surgical outcomes utilizing the ICD-ten-CM/PCS coding system, though these types of studies are on the horizon given that data from 2016, the kickoff full year of use of ICD-10-CM/PCS, are condign bachelor. The purpose of this review is to describe ICD-x-CM/PCS, demonstrate the strengths of the new format relative to thoracic surgical research and reveal potential challenges that may be encountered in utilizing administrative datasets with ICD-x-CM/PCS codes.

Construction of ICD-10-CM

ICD-10-CM describes diagnosis codes used for a variety of purposes, featured prominently in infirmary, convalescent surgical and clinic reimbursement (10). Each code consists of 3 to 7 alphanumeric characters starting with a letter and containing a decimal bespeak later on the tertiary character. The first three characters define which of the 21 chapters of disease categories contain the pathology in question. For case, malignancies of the respiratory tract or other intrathoracic organs are contained in the C30 through C39 section. Specifically, lung cancer would be defined by C34.10, where "x" indicates boosted numeric values to depict anatomic locations for a malignant lung neoplasm including laterality, upper, heart, lower lobe, overlapping sites or otherwise unspecified pulmonary sites. ICD-x-CM presents sixteen different codes for lung cancer due to the inclusion of laterality options in the disease definition ( Table i ).

Tabular array 1

ICD-10-CM diagnosis codes for lung cancer

ICD-x-CM code	Diagnosis
C34.00	Malignant neoplasm of unspecified main bronchus
C34.01	Cancerous neoplasm of right main bronchus
C34.02	Malignant neoplasm of left main bronchus
C34.ten	Malignant neoplasm of upper lobe, unspecified bronchus or lung
C34.11	Malignant tumour of upper lobe, correct bronchus or lung
C34.12	Malignant neoplasm of upper lobe, left bronchus or lung
C34.two	Malignant neoplasm of middle lobe, bronchus or lung
C34.xxx	Malignant tumour of lower lobe, unspecified bronchus or lung
C34.31	Malignant neoplasm of lower lobe, right bronchus or lung
C34.32	Cancerous neoplasm of lower lobe, left bronchus or lung
C34.eighty	Malignant neoplasm of overlapping sites of unspecified bronchus and lung
C34.81	Malignant neoplasm of overlapping sites of right bronchus and lung
C34.82	Malignant neoplasm of overlapping sites of left bronchus and lung
C34.90	Cancerous tumour of unspecified role of unspecified bronchus or lung
C34.91	Malignant tumour of unspecified part of correct bronchus or lung
C34.92	Malignant neoplasm of unspecified part of left bronchus or lung

ICD-10-CM, International Nomenclature of Diseases, 10^th Revision, Clinical Modification.

Structure of ICD-10-PCS

ICD-x-PCS provides the facility billing framework for procedures utilized past most infirmary systems, equally opposed to the Current Procedural Terminology (CPT) coding system (maintained by the American Medical Association) which is more ofttimes used for professional service billing by physician groups in the United States (11). While CPT codes often describe procedures in the context of a specific illness process, ICD-10-PCS procedures remain nonspecific to an underlying disease. A combination of 7 alphanumeric characters with no decimal points brand up every ICD-10-PCS code, with each graphic symbol describing a unique aspect of the procedure definition, as seen in the case of a thoracoscopic left upper lobectomy ( Figure 1 ). The get-go character represents the "Section" of the ICD-ten-PCS from which the process derives, with well-nigh all surgical procedures found nether "0" for "Medical and Surgical." The 2nd character defines the "Body Organization," with "B" representing the Respiratory System. The "Operation" character is important in defining the actual physical activity performed during the process. These "Operation" definitions include 31 possible options, each of which has a precise definition that may not deport with use of these terms outside of the context of coding. Thus, users must carefully select the advisable "Performance(s)" in determining which code(s) apply. In the aforementioned instance, "T" represents "resection." Once an "Operation" is chosen, the fourth graphic symbol represents the "Body Function," giving precise definitions to distinguish laterality likewise as anatomic components such equally the pulmonary lobe that was resected. The fifth graphic symbol, "Approach", provides the full spectrum of potential surgical approaches such as "percutaneous endoscopic," which indicates a thoracoscopic or laparoscopic technique, and "via natural or artificial opening, endoscopic" for bronchoscopic procedures. The sixth character, "Device", provides supplemental information on whatever implantation of autologous or synthetic tissues. The terminal character "Qualifier" provides unique additional information for each type of "Operation".

Structure of ICD-x-PCS process codes using an case for a left upper lobe thoracoscopic lobectomy. ICD-x-PCS, International Nomenclature of Diseases, 10^th Revision, Procedure Coding System.

A sublobar resection such as a wedge resection tin can be distinguished from a lobectomy past the "Operation" character of "B" for "excision," indicating removal of a portion of rather than the full anatomic body part as defined by the "Body Part" characteristic ( Figure 2 ). Additionally, the "Qualifier" portion can be coded equally "X" when a procedure is done for diagnostic rather than therapeutic purposes, as seen in the example of an open right upper lobe diagnostic wedge excision. A full pneumonectomy would be coded with a "T" (resection) for the "Operation" grapheme, but the distinction from a lobectomy comes from the "Body Part" designation of "K" or "Fifty" for the right lung or left lung in totality, respectively.

Structure of ICD-ten-PCS procedure codes using an example for an open up right upper lung lobe diagnostic wedge (i.e., sublobar) resection. ICD-10-PCS, International Classification of Diseases, 10^th Revision, Procedure Coding System.

By comparison, an esophagectomy is coded again in the "0" "Department" followed by "D" for "Body Arrangement" representing the gastrointestinal system. Ane example of an esophagectomy utilizes the "Operation" feature of "T" indicating a resection ( Figure 3 ), all the same the use of an excision "Functioning" characteristic of "B" seems equally appropriate because the boundaries of the body part options under 0DB and 0DT are non precisely defined, nor are surgeons likely to e'er describe the extent of esophageal resection in such a style that coders could readily determine whether the upper, eye, or lower esophagus was "excised" or "resected." Coders could conceivably draw a transhiatal esophagectomy using the "Operation" root of "extraction" (0DD). The "Torso Part" gives some detail as to the location of the tumor and which portion of the esophagus was resected, with "iii" representing the lower third of the esophagus. There is some additional detail bachelor with a "Trunk Function" of "4" representing an esophagogastric junction resection. Resection involving more than one third of the esophagus but non a total esophagectomy (which would exist signified by a "Body Function" indicator of "v", would require either a lawmaking for "excision" of the unabridged esophagus or "resection" of more than one esophageal body part. Similar to pulmonary resections, the "Approach" character allows for distinction between open and minimally invasive procedures, with "0" indicating an open approach, "3" for "percutaneous," "4" for "percutaneous endoscopic," "7" for "via natural or artificial opening," and "viii" for "via natural or artificial opening, endoscopic" options, depending on whether the "resection" or "excision" root applies. There is no additional particular in the "Device" or "Qualifier" characteristics for esophageal "resection" procedures.

Construction of ICD-10-PCS procedure codes using an example for an open esophagectomy of the lower 3rd of the esophagus. ICD-10-PCS, International Classification of Diseases, 10^th Revision, Process Coding System.

Strengths of ICD-10-CM/PCS

With the expansion in number of diagnosis and procedure codes available in ICD-10-CM/PCS, in that location is new detail within each code that tin benefit both health facilities and researchers. For instance, while ICD-9-CM distinguished betwixt upper, middle and lower lung lobes as the site of malignancy, ICD-10-CM adds specificity for laterality. ICD-9-CM previously redundantly coded esophageal malignancies either as cervical, thoracic or abdominal, as well as either upper, centre or lower tertiary of the esophagus. ICD-10-CM simplifies the diagnoses to neoplasms of the upper, middle or lower third of the esophagus, while adding a designation for overlapping sites of the esophagus.

The transition to ICD-x-PCS provides more specificity to track details of the operation. ICD-10-PCS provides in-depth anatomic specificity through the "Body Part" designation. Lobectomies tin can be designated by lobe as well as laterality, a distinction absent-minded from the CPT coding arrangement. Lobectomies can be divers in significant detail using the "resection" "Operation" designation, with 12 possible unique ICD-x-PCS codes defining a lobectomy ( Tabular array two ). Wedge resections and segmentectomies, while not differentiable from each other, tin exist coded with significant anatomic detail utilizing the "excision" "Operation" designation. Diagnostic and therapeutic excisions can exist distinguished with the "Qualifier" feature. In that location are 36 clinically plausible codes in ICD-x-PCS for defining a wedge resection or segmentectomy ( Table 3 ). Of note, one must consider that a wedge resection might exist coded correctly, albeit with less anatomic detail, utilizing the "Body Part" designations "K" and "L" for right lung and left lung, respectively, particularly if coders are unable to discern from the available documentation which lobe of the lung was involved. Such "Body Part" designations are not included for lobectomies ( Table 2 ) as they would instead represent a pneumonectomy when paired with a "resection" "Operation" designation. Besides, codes with approaches other than "open" or "percutaneous endoscopic" for lung tissue excisions (0BB) could not plausibly involve segmentectomy or wedge excision ( Tabular array 3 ), and instead would represent primarily bronchoscopic or percutaneous needle biopsies.

Table 2

ICD-10-PCS procedure codes for lobectomy (Section: Medical and Surgical; Body System: Respiratory Organization)

ICD-10-PCS code	Performance	Trunk office	Arroyo	Device	Qualifier
0BTC0ZZ	Resection	Upper lung lobe, correct	Open	No device	No qualifier
0BTC4ZZ	Resection	Upper lung lobe, right	Percutaneous endoscopic	No device	No qualifier
0BTD0ZZ	Resection	Heart lung lobe, right	Open	No device	No qualifier
0BTD4ZZ	Resection	Middle lung lobe, right	Percutaneous endoscopic	No device	No qualifier
0BTF0ZZ	Resection	Lower lung lobe, correct	Open up	No device	No qualifier
0BTF4ZZ	Resection	Lower lung lobe, right	Percutaneous endoscopic	No device	No qualifier
0BTG0ZZ	Resection	Upper lung lobe, left	Open	No device	No qualifier
0BTG4ZZ	Resection	Upper lung lobe, left	Percutaneous endoscopic	No device	No qualifier
0BTH0ZZ	Resection	Lung lingula	Open	No device	No qualifier
0BTH4ZZ	Resection	Lung lingula	Percutaneous endoscopic	No device	No qualifier
0BTJ0ZZ	Resection	Lower lung lobe, left	Open	No device	No qualifier
0BTJ4ZZ	Resection	Lower lung lobe, left	Percutaneous endoscopic	No device	No qualifier

ICD-10-PCS, International Classification of Diseases, 10^th Revision, Procedure Coding Organization.

Table three

ICD-10-PCS procedure codes for wedge resection or segmentectomy (Section: Medical and Surgical; Body System: Respiratory System)

ICD-10-PCS code	Operation	Body part	Approach	Device	Qualifier
0BBC0ZX	Excision	Upper lung lobe, right	Open up	No device	Diagnostic
0BBC0ZZ	Excision	Upper lung lobe, right	Open	No device	No qualifier
0BBC4ZX	Excision	Upper lung lobe, correct	Percutaneous endoscopic	No device	Diagnostic
0BBC4ZZ	Excision	Upper lung lobe, right	Percutaneous endoscopic	No device	No qualifier
0BBD0ZX	Excision	Center lung lobe, right	Open	No device	Diagnostic
0BBD0ZZ	Excision	Middle lung lobe, right	Open	No device	No qualifier
0BBD4ZX	Excision	Center lung lobe, right	Percutaneous endoscopic	No device	Diagnostic
0BBD4ZZ	Excision	Heart lung lobe, correct	Percutaneous endoscopic	No device	No qualifier
0BBF0ZX	Excision	Lower lung lobe, right	Open	No device	Diagnostic
0BBF0ZZ	Excision	Lower lung lobe, right	Open	No device	No qualifier
0BBF4ZX	Excision	Lower lung lobe, correct	Percutaneous endoscopic	No device	Diagnostic
0BBF4ZZ	Excision	Lower lung lobe, correct	Percutaneous endoscopic	No device	No qualifier
0BBG0ZX	Excision	Upper lung lobe, left	Open	No device	Diagnostic
0BBG0ZZ	Excision	Upper lung lobe, left	Open	No device	No qualifier
0BBG4ZX	Excision	Upper lung lobe, left	Percutaneous endoscopic	No device	Diagnostic
0BBG4ZZ	Excision	Upper lung lobe, left	Percutaneous endoscopic	No device	No qualifier
0BBH0ZX	Excision	Lung lingula	Open	No device	Diagnostic
0BBH0ZZ	Excision	Lung lingula	Open	No device	No qualifier
0BBH4ZX	Excision	Lung lingula	Percutaneous endoscopic	No device	Diagnostic
0BBH4ZZ	Excision	Lung lingula	Percutaneous endoscopic	No device	No qualifier
0BBJ0ZX	Excision	Lower lung lobe, left	Open up	No device	Diagnostic
0BBJ0ZZ	Excision	Lower lung lobe, left	Open up	No device	No qualifier
0BBJ4ZX	Excision	Lower lung lobe, left	Percutaneous endoscopic	No device	Diagnostic
0BBJ4ZZ	Excision	Lower lung lobe, left	Percutaneous endoscopic	No device	No qualifier
0BBK0ZX	Excision	Lung, right	Open	No device	Diagnostic
0BBK0ZZ	Excision	Lung, right	Open up	No device	No qualifier
0BBK4ZX	Excision	Lung, correct	Percutaneous endoscopic	No device	Diagnostic
0BBK4ZZ	Excision	Lung, correct	Percutaneous endoscopic	No device	No qualifier
0BBL0ZX	Excision	Lung, left	Open	No device	Diagnostic
0BBL0ZZ	Excision	Lung, left	Open	No device	No qualifier
0BBL4ZX	Excision	Lung, left	Percutaneous endoscopic	No device	Diagnostic
0BBL4ZZ	Excision	Lung, left	Percutaneous endoscopic	No device	No qualifier
0BBM0ZX	Excision	Lungs, bilateral	Open	No device	Diagnostic
0BBM0ZZ	Excision	Lungs, bilateral	Open	No device	No qualifier
0BBM4ZX	Excision	Lungs, bilateral	Percutaneous endoscopic	No device	Diagnostic
0BBM4ZZ	Excision	Lungs, bilateral	Percutaneous endoscopic	No device	No qualifier

ICD-x-PCS, International Classification of Diseases, 10^th Revision, Procedure Coding System.

There is meaning specificity under "Body Parts" for bronchial beefcake, allowing for the pairing of a code for a lobectomy "resection" with that of the advisable bronchial "resection" to depict a sleeve lobectomy. One could fifty-fifty utilize an isolated "resection" or "excision" code with the "Body Part" of "Chief Bronchus, Right" or "Main Bronchus, Left" to describe a bronchoplastic sleeve resection without lobectomy that would exist used for an isolated airway tumor.

Esophagectomies also accept enhanced specificity in ICD-x-PCS coding, which allows for defining a specific subset of patients (e.g., for research purposes) using 20 of the most clinically plausible ICD-10-PCS codes ( Table iv ). Notably, both the "excision" and "resection" "Operation" designations are valid for an esophagectomy. Use of the "bypass" "Functioning" indicator of "1" would not fairly describe an esophagectomy on its ain, but it would describe the reconstruction or anastomosis portion of the esophagectomy procedure (just every bit a "drainage" functioning root would apply to esophagostomy). Nonetheless, depending on the context, both a code for esophagectomy and a lawmaking for reconstruction or diversion may exist necessary to ascertain circumstances of esophagectomy.

Tabular array 4

ICD-10-PCS process codes for esophagectomy (Section: Medical and Surgical; Trunk System: Gastrointestinal Organization)

ICD-10-PCS code	Functioning	Body office	Approach	Device	Qualifier
0DB10ZZ	Excision	Esophagus, upper	Open	No device	No qualifier
0DB14ZZ	Excision	Esophagus, upper	Percutaneous endoscopic	No device	No qualifier
0DB20ZZ	Excision	Esophagus, heart	Open	No device	No qualifier
0DB24ZZ	Excision	Esophagus, heart	Percutaneous endoscopic	No device	No qualifier
0DB30ZZ	Excision	Esophagus, lower	Open	No device	No qualifier
0DB34ZZ	Excision	Esophagus, lower	Percutaneous endoscopic	No device	No qualifier
0DB40ZZ	Excision	Esophagogastric junction	Open	No device	No qualifier
0DB44ZZ	Excision	Esophagogastric junction	Percutaneous endoscopic	No device	No qualifier
0DB50ZZ	Excision	Esophagus	Open	No Device	No Qualifier
0DB54ZZ	Excision	Esophagus	Percutaneous Endoscopic	No Device	No Qualifier
0DT10ZZ	Resection	Esophagus, upper	Open	No device	No qualifier
0DT14ZZ	Resection	Esophagus, upper	Percutaneous endoscopic	No device	No qualifier
0DT20ZZ	Resection	Esophagus, middle	Open	No device	No qualifier
0DT24ZZ	Resection	Esophagus, middle	Percutaneous endoscopic	No device	No qualifier
0DT30ZZ	Resection	Esophagus, lower	Open	No device	No qualifier
0DT34ZZ	Resection	Esophagus, lower	Percutaneous endoscopic	No device	No qualifier
0DT40ZZ	Resection	Esophagogastric junction	Open	No device	No qualifier
0DT44ZZ	Resection	Esophagogastric junction	Percutaneous endoscopic	No device	No qualifier
0DT50ZZ	Resection	Esophagus	Open	No device	No qualifier
0DT54ZZ	Resection	Esophagus	Percutaneous endoscopic	No device	No qualifier

The "Arroyo" designation becomes important in distinguishing thoracoscopic versus open techniques. A "percutaneous endoscopic" approach is used to code for thoracoscopic and laparoscopic techniques. There is presently no method to differentiate between a video-assisted versus a robotic-assisted thoracoscopic surgery utilizing ICD-10-PCS, as the "Arroyo" designation of "percutaneous endoscopic" is employed for both procedure types with no further differentiation bachelor within the "Device" or "Qualifier" designations. Of note, bronchoscopy, including endobronchial ultrasound, and esophagogastroduodenoscopy (EGD) procedures are coded every bit "via a natural or artificial opening endoscopic" (though there is no boosted "Device" or "Qualifier" designations to account for use of ultrasound during an EGD). Mediastinoscopy is coded as a percutaneous endoscopic approach, although it is important to note that mediastinoscopy falls under the "Anatomic Regions, Full general" "Torso System" coded equally "0W." Official guidelines instruct coders that, if an intended procedure is discontinued, they should code the procedure to the root operation performed. This exercise volition allow researchers to use this "Approach" designation to evaluate questions such equally which patients undergo intraoperative conversion from thoracoscopic arroyo to a thoracotomy past sampling for patients with both process codes (due east.g., combination of a "percutaneous endoscopic" "inspection" lawmaking along with an "open up" "resection" code). Thus, the significant detail enwrapped in each procedure lawmaking is potentially beneficial to researchers investigating specific topics.

Challenges of ICD-x-CM/PCS

With the 10^th revision of ICD come a number of new challenges in both billing and utilization of administrative datasets for outcomes inquiry. While ICD-x-PCS will be highly pertinent for clinicians analyzing surgical outcomes, these coding data will often need to exist paired with ICD-10-CM diagnosis data because of the lack of disease-specific information in the new procedural codes. ICD-10-PCS procedure codes are agnostic to the underlying illness process associated with the procedure. A thoracotomy tin can be performed for a myriad of reasons such every bit diagnosis, therapy for a benign procedure, therapy for a cancer process or palliation. Information technology therefore becomes vital to use more than involved logic based on the ICD-10-CM diagnosis codes when a specific patient cohort is desired, such every bit those undergoing therapeutic lobectomy for lung cancer. Unfortunately, the ICD-10-CM codes for neoplasms are non-specific for cancer staging information or histology, then users volition take to obtain more detailed oncologic characteristics from other data sources.

The ICD-x-PCS "Operation" character is vital to selecting the correct procedure codes, and prospective researchers should be familiar with the definitions of the 31 root operations. Of particular importance is the definition of "excision," which refers to fractional removal of a trunk office, as opposed to "resection," which involves the consummate removal of a trunk part. The definition of a consummate trunk part is variable depending on the relevant beefcake. A pulmonary lobectomy of the correct upper lobe is the removal of a complete correct upper pulmonary lobe, and thus is a "resection" of a complete anatomical unit ( Table 2 ). A segmentectomy of the correct upmost segment, though removing the unabridged segment, does non remove an entire torso office as divers past the "Trunk Part" options inside the Respiratory System affiliate of ICD-10-PCS, and would thus establish an "excision" ( Table 3 ). A pulmonary wedge resection would also plant an "excision," and therefore cannot be differentiated from a segmentectomy. As such, researchers may demand to define such surgical populations every bit patients undergoing sublobar resections without the specificity of a segmentectomy versus wedge resection. In comparison, ICD-ix-CM offered process codes for "thoracoscopic segmental resection of the lung" (32.xxx) versus "other excision of lung" (32.90), "thoracoscopic lung biopsy" (33.20), "airtight endoscopic biopsy of lung" (33.27), and "open up biopsy of lung" (33.28), which might signify wedge resections. Additionally, one must exist aware that ICD-x-PCS codes for "excision" under the "Body System" "Respiratory Arrangement" allow for a variety of "Approaches" including "percutaneous," "via natural or artificial opening," and "via natural or artificial opening endoscopic approaches." These three "Approaches" are not consequent with how a sublobar resection would clinically be performed, but researchers should be aware of their existence to account for the possibility of miscoding past coders.

There is some ambivalence in the coding of bilobectomy, as a coder might apply two codes with the "resection" "Operation" character to describe the two private lobes that were resected. Alternatively, a coder could conceivably utilise a code under the "excision" "Operation" graphic symbol such every bit 0BBK0ZZ (excision of the correct lung via an open approach) to describe removal of less than the full right lung as a representation of a bilobectomy. Additionally, as previously discussed there is some ambivalence in the coding of a sleeve lobectomy which could pb to coder error in accurately defining the operation. While clinically it would exist most logical to pair a lobectomy "resection" code with the appropriate bronchus "resection" code, ane could conceivably utilize a bronchus "excision" code likewise. Information technology is also unclear what a bronchus "resection" would consist of without pairing the lawmaking with the appropriate lobectomy "resection" because a lobar bronchus "resection" by its nature has to include the pulmonary parenchyma associated with the bronchus.

A thoracic lymph node biopsy via mediastinoscopy should commonly be coded as an excision (07B74ZX) when individual lymph nodes from specific lymph node stations are sampled (12). Every bit such, the potential aggregation of process codes needed to capture all patients undergoing a specific procedure quickly becomes large and circuitous. While coders are instructed past the Official Guidelines for Coding and Reporting to utilize the correct root "Operation" character regardless of how the operating physician words the procedure in their documentation, there is certainly room for ambiguity and unintentional miscoding, which could bear upon accurate sampling of patient cohorts for inquiry (11). An institution might incorrectly code their lobectomies as an "excision" of a lung rather than a "resection" of a lung lobe, leading to nether-selection of available patients for a inquiry accomplice.

The complexity of the "Functioning" characteristic is exemplified in the potential codes required to capture all possible instances of an esophagectomy ( Table 4 ). It is not clear which "Operation" codes are near correct in defining an esophagectomy. An esophagectomy involving the lower third of the esophagus might correctly exist coded as a "resection" when the entire lower third of the esophagus is removed, whereas it might be more authentic to code as an "excision" when less than the entirety of the lower third of the esophagus is removed. Coding an esophagectomy as an "excision" so clouds the distinction between esophagectomy and excisional biopsy, unless the diagnostic "Qualifier" is accordingly practical. A third "Operation" characteristic that appears to accurately describe portions of an esophagectomy operation is the "bypass" operation. While this "Performance" appears to add some detail in describing the altered route of passage of the contents of a tubular trunk part, the Official Guidelines for Coding and Reporting part B3.1b state that components of a process (such as anastomosis of a tubular trunk part) that are a part of the root operation definition (such as resection of a tubular body part) are not coded separately (xi). The resulting interpretation—which we believe is problematic—is that an esophagectomy implies that an anastomosis was too performed, thus making a "featherbed" lawmaking redundant and unnecessary. However, an esophagectomy could be performed with reanastomosis, creation of a cervical esophagostomy, or leaving a portion of the esophagus in situ every bit a blind pouch. In such situations, the ambiguity of the "resection" "Operation" lonely seems to require further specification by an boosted "featherbed" or "drainage" lawmaking. The "bypass" "Operation" adds some express additional information regarding the nature of the bypass conduit. The "Body Part" characteristic specifies the torso part bypassed from, while the "Qualifier" in bypass coding refers specifically to the distal body part that is beingness bypassed to. Equally such, a direct esophagojejunal anastomosis (0D150ZA) is definable when a total gastrectomy with partial esophagectomy is required, using the proximal "Body Part" of esophagus and the distal "Qualifier" of jejunum. A cervical esophagostomy (0D110Z4) is definable using the "Esophagus, Upper" as the proximal and "Cutaneous" equally the distal sites of the "bypass." Use of the "Device" characteristic allows for differentiation between an esophagectomy with a gastric conduit (0D150Z6) using "No Device" as compared to a colonic interposition or jejunal interposition bypass conduit (0D15076) using "Autologous Tissue Substitute" for the "Device." Unfortunately, there does not appear to be a style to distinguish betwixt a colonic or jejunal interposition featherbed conduit. Such detail was definable in the ICD-9-CM Volume iii with codes for "intrathoracic esophago-esophagostomy," "intrathoracic esophagogastrostomy," "intrathoracic esophageal anastomosis with interposition of pocket-sized bowel," or "intrathoracic esophageal anastomosis with interposition of colon," in addition to "antesternal" codes for all of the to a higher place procedures. Thus significant anatomic detail has been removed from ICD-ten-PCS. In any case, many ICD-10-PCS codes remain and must exist employed to capture all appropriate subjects in whatsoever analysis evaluating esophagectomy patients ( Table 4 ).

While an open versus minimally invasive esophagectomy can be differentiated based on the "Approach," there is no reliable way—even with all the complexity of ICD-ten-PCS—to differentiate betwixt mutual esophagectomy techniques such as transhiatal, McKeown 3-hole, Ivor Lewis, or thoracoabdominal esophagectomy, although some process categorization may be inferred based on the use of thoracotomy and location of the anastomosis, i.east., cervical or intrathoracic. Eponyms are by and large not permitted in ICD-ten-PCS; coding guidelines encourage the utilize of a combination of codes to describe all of the relevant components of a complex procedure. Every bit a result, strategies for patient population selection from authoritative datasets using ICD-x-PCS may require specific combinations of multiple codes (e.g., at least ane from List A and at least one from List B). To select reproducible patient cohorts without selection bias, users should account for the numerous coding possibilities present in ICD-10-CM/PCS. Accurate descriptions of the data choice method to create a patient cohort from population based administrative datasets should be included in the Methods section of whatever such studies. In fact, the REporting of studies Conducted using Observational Routinely-collected Data (RECORD) group collaborative guidelines recommends documentation as such: "Tape 6.ane: The methods of study population choice (such as codes or algorithms used to place subjects) should be listed in detail. If this is non possible, an caption should be provided. Tape vi.2: Any validation studies of the codes or algorithms used to select the population should be referenced. If validation was conducted for this study and non published elsewhere, detailed methods and results should exist provided" (thirteen).

Finally, i must be aware that the item inherent in ICD-10-PCS can lead to coding of some procedures that are impractical or implausible. Some examples of such unrealistic or unlikely procedures include percutaneous endoscopic resection of the lungs (bilateral), percutaneous fragmentation of the carina, endoscopic resection of the entire esophagus and endoscopic bypass from the upper esophagus to the ileum with a synthetic substitute. While these possibilities take little or no clinical use, they be in ICD-10-PCS and therefore could inadvertently be selected past a misinformed coder. Such procedures of dubious merit could be pruned from the coding classification through the ICD-10-CM/PCS Coordination and Maintenance Committee, only until that fourth dimension researchers must consider the possibility of miscoding of procedures that are of actual interest.

Conclusions

ICD-x-CM/PCS is a robust tool for the clinical researcher aiming to harness the power of large administrative datasets. It is vitally important that coders piece of work in conjunction with surgeons to ensure that correct and optimized codes are consistently used for specific procedures. Additionally, a keen understanding of the workings of the coding system is necessary to employ it as a patient selection tool for large population datasets in a logical manner. In that location are many potential missteps to navigate, and it is therefore vitally of import for researchers and journal editors alike to understand and concur upon research methods that are accurate and coherent when utilizing ICD-ten-CM/PCS diagnosis and procedure codes. This commodity proposes some of the procedure codes that may exist relevant in defining a population of thoracic surgery patients, but time to come work will need to constitute and validate additional good practices for the application of this coding organization to thoracic surgical clinical research efforts.

Footnotes

Conflicts of Involvement: The authors have no conflicts of involvement to declare.

References

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6465427/

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