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Does an ICD-10-PCS code require an accompanying CM code to accurately identify a procedure?

General
#1

Am I right in assuming that in many cases PCS codes require an accompanying ICD DX code in order to identify a procedure? For example, I tried finding a PCS code for a Pilonidal Sinus Excision. The closest code I see is fairly generic: 0HB8XZZ Excision of Buttock Skin, External Approach.
Unless I’m wrong, this same PCS code looks like the only option for other similar conditions, like:
Pilonidal cyst with abscess,
Pilonidal cyst without abscess,
Pilonidal sinus with abscess,
Pilonidal sinus without abscess.

The above look like multiple ICD DX per 1 PCS. It happens the other way, too. For example, when looking up a vasectomy, I see one ICD-10-CM code: Z98.52, however there appear to be multiple PCS codes for the same diagnosis --I’m guessing traditional and no scalpel(?):
0VBQ0ZZ Excision of Bilateral Vas Deferens, Open Approach
0VBQ3ZZ Excision of Bilateral Vas Deferens, Percutaneous

So, is the combination of ICD-10-CM and PCS required, and if so, how can I get a list of valid mappings between the two?

#2

@TylerWilson:

I assume you are asking about an US healthcare artifact, since all countries have their idiosyncrasies. But you have a good point, because the rules what code can or must be claimed together with which other code are completely intransparent. So, if you have a surgical practice doing these excisions how will you find out? There is no one source of these rules:

  • Some rules are set by the CMS
  • Some by the medical association relevant to you
  • EHR vendors end up setting de-facto rules through the built-in code sets
  • There is a cottage industry of consultants making good money telling the providers how to bill right
  • Each insurance company may add their own rule and return your claim if deemed not sufficient or relax a rule

And all this is specialty by specialty.

So, if you solve this case, and it won’t be simple and straightforward, please share with the community, so at least we will learn how to track down this kind of information.

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#3

I’ll be glad to share if I come across any solution for this mess. =) Can you describe how to get the rules set by CMS? I’m interested in the most permissive mapping that is freely available, since I’m not interested in actual billing.

#4

Beats me. Google it. First thing that comes up is https://www.aapc.com/blog/34156-pilonidal-cyst-11770-11772/. Hire a billing specialist. We need to figure that out.

Aren’t you working off of the bill you got for your son?

#5

I just paid cash since it was significantly cheaper than the rate “negotiated” by my insurance. =) So, I didn’t even see a code in my bill.
What I’m really interested in is an industry standard list of user-friendly names and codes for medical procedures/services. I first looked into CPT, but soon gave up on that as the AMA has a stranglehold on those and I can’t afford the licensing for wide use. My next thought was to try to use ICD-10-PCS since those are free, however, they can’t stand on their own as discussed above, and even if they could, the terminology is far from user-friendly in my opinion. So, I’m now looking into OMOP vs UMLS vs SNOMED-CT. Can you recommend one of these (or other?) that meets the following criteria:

  1. available for free --I would like to incorporate this into my website. It will be free to the general public, but I may charge for advertising
  2. includes the ability to group entries that are similar enough into 1 standard concept (to use the terminology in OMOP).
  3. (icing on the cake) includes lay terms, i.e., searching for tummy tuck would find abdominoplasty

The OMOP Vocabulary looks promising, but is there a lighter-weight database that will accomplish the above?

#6

SNOMED procedures is probably your best choice. But if you want to use it outside observational research for your website you will need to get your own SNOMED license. It’s free.

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