ICD-10 PCS: Harnessing the Power of Procedure Codes

The transition to ICD-10 in 2015 saw the number of available procedure codes increase from roughly 3,000 to more than 70,000. This change gives clinicians the ability to code procedures to a much higher degree of specificity and provides health systems the ability to unlock powerful clinical insights into how inpatient procedural care is delivered.

This article covers the benefits and drawback of ICD-10 PCS, as well as concrete ways health systems can use these procedure codes to provide new clinical insights. The article also walks through the anatomy of the seven-digit alphanumeric codes and provides specific clinical examples of how healthcare organizations can slice and dice this data.

1. ICD-10 PCS: Harnessing the Power of Procedure Codes

2. When the U.S. healthcare system transitioned from ICD-9 to ICD-10 codes in 2015, this brought the number of available *PCS codes from roughly 3,000 to more than 70,000. This drastic increase means clinicians can code procedures with a much higher degree of specificity. And, ICD-10-CM diagnosis codes also increased from 13,000 to 68,000. Harnessing the Power of Procedure Codes *Procedure Coding System , a U.S. classification system referring to procedures in an inpatient setting

3. Although the shift to ICD-10 required healthcare organizations to change how medical encounters are documented, doing so gives organizations the ability to harness powerful analytics behind ICD-10 PCS codes. Armed with new insights into how inpatient procedural care is delivered, health systems can improve patient outcomes and value. Harnessing the Power of Procedure Codes

4. Health Catalyst uses a Clinical Integration Hierarchy , which allows for more precise analysis of the care provided and 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. Building Procedural Integration Hierarchies for Analytic Insights

5. 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 analytic insights using procedure data as well as leveraging the higher degree of specificity that ICD-10 allows. Building Procedural Integration Hierarchies for Analytic Insights

6. The addition of a procedural integration hierarchy will complement the clinical integration hierarchy and allow clinicians and hospital leaders more contextual information. For instance, in looking at transplant patients by diagnosis codes, we are currently unable to identify if they had the transplant on the current encounter, or was the admission related to underlying management of their medical condition. Building Procedural Integration Hierarchies for Analytic Insights

7. This is crucial information when looking at variation in costs, length of stay 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.). Building Procedural Integration Hierarchies for Analytic Insights

8. All three patients would show as having colectomies but the length of stay (LOS), processes, and outcomes could be intentionally different. Neither coding tool provides a full picture as we are looking at single variables when classifying a patient stay, which is why 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. Building Procedural Integration Hierarchies for Analytic Insights

9. The International Classification of Diseases (ICD) was initially developed and published by the World Health Organization (WHO) to standardize healthcare reporting worldwide. 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. Benefits of ICD-10 PCS Codes

10. Even though the transition to ICD-10 in 2015 disrupted the healthcare industry, the potential analytic benefits likely outweighed the disruption: Benefits of ICD-10 PCS Codes 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 – The structure is designed to be scalable as new procedures are added or new technologies come into play. Standardized Terminology – Provides precise and stable definitions of all procedures performed and reflects current usage of medical terminology and devices. > > >

11. Figure 1: The structure of ICD-10 PCS allows for a very high-degree of specificity about medical procedures with seven alphanumeric characters. Benefits of ICD-10 PCS Codes

12. 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. ( See figure 1 ) Benefits of ICD-10 PCS Codes

13. Specificity 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 Benefits of ICD-10 PCS Codes

14. Specificity Benefits of ICD-10 PCS Codes Figure 2: Sample Root Operation Table. Source: CMS data .

15. 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. Additionally, the definition of each character is a function of its physical position in the code. Benefits of ICD-10 PCS Codes

16. Precision and Laterality For example, the fifth character of the procedure code refers to the approach type, so a hospital administrator could look at the total volume of open procedures or the total volume of minimally invasive surgeries using just the fifth character. Adding the seventh character, an administrator could look at the total number of biopsies performed across the system on a specific body part, for example. These examples help highlight the powerful level of specificity available for analysis using procedure codes. Benefits of ICD-10 PCS Codes

17. Scalable ICD-9 procedure codes contained only three to five numeric characters, limiting space for adding new codes. ICD-10 PCS was designed to have the flexibility for adding new codes as new procedures are added or new technologies come into play. Benefits of ICD-10 PCS Codes

18. 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. Benefits of ICD-10 PCS Codes

19. Drawbacks include the following: ICD-10 PCS is specific to the U.S. (not used in either England or Canada). ICD-10 does not include eponyms, common procedure names, terms, or acronyms. It can be necessary to look at secondary procedure codes in order to correctly identify the type of surgery performed. Drawbacks of ICD-10 PCS > > >

20. The standardization of procedure codes brought stability and eliminated outdated terminology but did result in the limitations noted above. A good example is the elimination of eponyms, which resulted in the elimination of some well-known procedures like the Whipple , defined by the Mayo Clinic as: …an operation to remove the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder and the bile duct.” Drawbacks of ICD-10 PCS

21. With ICD-9, the Whipple was coded as Radical Pancreaticoduodenectomy, better known as a 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). Excision of stomach, open approach (0DB60ZZ). Resection of stomach, pylorus, open approach (0DT70ZZ). Drawbacks of ICD-10 PCS > > > > > > >

22. 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 at just 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. Drawbacks of ICD-10 PCS

23. 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. Drawbacks of ICD-10 PCS 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)

24. 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. Drawbacks of ICD-10 PCS

25. Health Catalyst’s Clinical Integration Hierarchy provides access to complete, contextual information that may bring healthcare systems new and unique clinical insights. With the addition of the Procedural Hierarchy, clinicians and administrators could look at the procedure codes in conjunction with the principle discharge diagnosis to gain insight into why the patient was hospitalized in the first place. Procedural and Clinical Hierarchy Combine to Give New Insights

26. Or, they could look at what type of surgeon is performing a procedure and how the outcomes compare to a different type of surgical specialty performing the same operation. Insights can then be shared in order to improve patient outcomes and analytics can be used to facilitate such conversations. The multitude of scenarios this Procedural Hierarchy can impact are broad. Procedural and Clinical Hierarchy Combine to Give New Insights

27. A health system could build clinically defined criteria, based upon current best-practice recommendations, incorporating procedure-based logic that 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. Procedural and Clinical Hierarchy Combine to Give New Insights

28. 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. Procedural and Clinical Hierarchy Combine to Give New Insights

29. As with other development, Health Catalyst is employing a pragmatic approach by using the Pareto principle in 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. Procedural and Clinical Hierarchy Combine to Give New Insights

30. 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. 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). Procedural and Clinical Hierarchy Combine to Give New Insights

31. 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. Procedural and Clinical Hierarchy Combine to Give New Insights

32. For more information: “This book is a fantastic piece of work” – Robert Lindeman MD, FAAP, Chief Physician Quality Officer

33. More about this topic Link to original article for a more in-depth discussion. ICD-10 PCS: Harnessing the Power of Procedure Codes Care Management Analytics: Six Ways Data Drives Program Success KimSu Marder, RN, CCM, Lead Care Manager How to Apply Machine Learning in Healthcare to Reduce Heart Failure Readmissions Brian Crick, MBA , Manager of Heart Failure and Arrhythmia Programs, Multicare Holly Burke, Director of Clinical Innovation, Pulse Heart Institute; Needham Ward, MD, CMO, Pulse Heart Institute Prioritizing Healthcare Projects to Optimize ROI Dorian DiNardo, Senior Vice President of Analytics; Aaron Neiderhiser , Product Management, Sr. Director How the Change to ICD-10 Codes Will Improve Healthcare Analytics Cessily Johnson, Director of Terminology Services 5 Ways to Use the ICD-10 Delay to Create a Competitive Advantage for Your Health System Cessily Johnson, Director of Terminology Service

34. Josh is a nurse practitioner who has over 20 years of nursing experience. Most recently, Josh joined Health Catalyst as a Clinical Outcomes Improvement Director. In this role, he helps healthcare organizations achieve their improvement goals. Prior to joining Health Catalyst, Josh worked at Intermountain Healthcare in a respiratory and medical intensive care unit as a nurse practitioner. During this time, he also worked closely with multiple clinical program leads and clinicians to develop and implement systemwide applications, protocols, and order sets to reduce variation in care. You will also, on occasion, find him lecturing to nurse practitioner students at the University of Utah. Other Clinical Quality Improvement Resources Click to read additional information at www.healthcatalyst.com Josh Ferguson, APRN, ACNP, ANP-BC

35. Other Clinical Quality Improvement Resources Click to read additional information at www.healthcatalyst.com Health Catalyst is a mission-driven data warehousing, analytics and outcomes-improvement company that helps healthcare organizations of all sizes improve clinical, financial, and operational outcomes needed to improve population health and accountable care. Our proven enterprise data warehouse (EDW) and analytics platform helps improve quality, add efficiency and lower costs in support of more than 65 million patients for organizations ranging from the largest US health system to forward-thinking physician practices. Health Catalyst was recently named as  the leader in the enterprise healthcare BI market in improvement by KLAS , and has received numerous best-place-to work awards including  Modern Healthcare in 2013, 2014, and 2015 , as well as other recognitions such as “ Best Place to work for Millenials , and a “ Best Perks for Women .”