Hospital inpatient procedure reporting is governed primarily by the Uniform Hospital Discharge Data Set (UHDDS) reporting criteria, in addition to payer-specific guidelines. The UHDDS indicates that all “significant procedures” should be reported in the short-term, acute-care hospital setting. It defines “significant procedures” as those that meet any of the following criteria: being surgical in nature, carrying a procedural or anesthetic risk, or requiring specialized training to perform. With such a broad description, one is hard-pressed to pinpoint an inpatient procedure that would not meet at least one of these criteria. These reportable procedures would include such common objectives as incision, excision, repair, suture, destruction, etc. The wide range of procedures meeting the UHDDS reporting criteria may differ from those that are required by payers, however. For example, the Centers for Medicare & Medicaid Services (CMS) requires reporting of all procedures that impact the MS-DRG. And procedure reporting guidelines do not end there. In just 18 short months, all entities covered by HIPAA will be required to utilize the 2014 version of the ICD-10-PCS code set to report inpatient procedures. The new Procedure Coding System (PCS) contains 71,924 codes andreplaces ICD-9-CM Volume 3, which contains 3,882 codes. The dramatic increase in the volume of codes is due in part to an expanded terminology that allows all substantially different procedures to have a unique code. There is also the use of a new multi-axial approach that results in the building of an ICD-10-PCS code consisting of seven characters. This is in stark contrast to ICD-9-CM procedure codes, which are assigned based on action terms and consist of three to four digits. It is this transition to a multi-axial structure with expanded terminology that has contributed to the nearly 19-fold increase in procedure code options. The new structure allows for the reporting of enhanced specificity and greatly improves expandability. This alleviates the need to transition to yet another procedure reporting classification system in the decades to come. The PCS structure is such that it can accommodate the need for future expansion to capture new approaches, techniques, technology, and devices to keep pace with our thirst for improved data capture regarding outcomes and quality of care.

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