HIT ICD10PCS

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ICD-10-PCS

(International Classification of Diseases - Procedure Coding System)


Differences between ICD-9-CM and ICD-10-PCS

(Karla R Lovaasen)

ICD-9-CM ICD-10-PCS
Structure Similar to ICD-9 Diagnosis Codes Structure Different with Use of Tables
Limited Number of Codes Expandable with Unlimited Number of Codes
Codes are 3 to 4 Digits with Decimal All Codes 7 Characters, NO Decimal after 2nd Digit
Codes are Numeric Codes are Alphanumeric
0-9 0-9, A-Z (except I and O)
Combination Codes Separate Procedures Performed at Same Time are Coded Separately

Organization of ICD-10-PCS

(Karla R Lovaasen)
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  • ICD-10-PCS Sections
    (CMS, Development of ICD-10-PCS)
  • ICD-10-PCS Has a Seven (7) Character Alphanumeric Code Structure
  • Each Character Contains Up to 34 Possible Values
  • Each Value Represents a Specific Option for the General Character Definition
    (e.g., Stomach is One of the Values for the Body Part Character)

• Digits 0-9 and 24 Letters A-H,J-N and P-Z May be Used in Each Character (Letters O and I are NOT Used in Order to Avoid Confusion With Digits 0 And 1)

  • Procedures are Divided Into Sections That Identify the General Type of Procedure
    (e.g., Medical and Surgical, Obstetrics, Imaging)
  • 1st Character of the Procedure Code Always Specifies the Section
    • 0. Medical and Surgical
    • 1. Obstetrics
    • 2. Placement
    • 3. Administration
    • 4. Measurement and Monitoring
    • 5. Extracorporeal Assistance and Performance
    • 6. Extracorporeal Therapies
    • 7. Osteopathic
    • 8. Other Procedures
    • 9. Chiropractic
    • B. Imaging
    • C. Nuclear Medicine
    • D. Radiation Oncology
    • F. Physical Rehabilitation and Diagnostic Audiology
    • G. Mental Health
    • H. Substance Abuse Treatment
  • 2nd Through 7th Characters Mean the Same Thing Within Each Section,
    But May Mean Different Things in Other Sections
  • In All Sections, the 3rd Character Specifies the General Type of Procedure Performed
    (e.g., Resection, Transfusion, Fluoroscopy)
  • The Other Characters Give Additional Information Such as
    the Body Part and Approach
  • The Term Procedure Refers to
    the Complete Specification of the Seven (7) Characters


ICD-10-PCS Format

(CMS, Development of ICD-10-PCS)
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  • ICD-10-PCS Is Made Up of Three (3) Separate Parts:
  1. Tables
    • Must Be Used In Order to Construct a Complete and Valid Code
  2. Index
    • Allows Codes to be Located By an Alphabetic Lookup
    • Entry Refers to a Specific Location in the Tables
  3. List of Codes
    • Provides a Comprehensive Listing of All Valid Codes,
      With a Complete Text Description Accompanying Each Code

1-Tables in ICD-10-PCS

(CMS, Development of ICD-10-PCS)
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  • Example: Value 027 Specifies
1. Section: (0) Medical and Surgical
2. Body System: (2) Heart and Great Vessels
3. Root Operation: (7) Dilation
  • Row from the Tables specifies the valid combinations of Characters 4 through 7
    for the Medical and Surgical Root Operation-Dilation of the Heart and Great Vessels-Body System (027)
    • (0) Medical and Surgical
    • (2) Heart and Great Vessels
    • (7) Dilation (Expanding an Orifice or the Lumen of a Body Part-Tubular)
Body Part Approach Device Qualifier
0 Coronary Artery, One Site

1 Coronary Arteries, Two Sites
2 Coronary Arteries, Three Sites
3 Coronary Arteries, Four or More Sites

0 Open

3 Percutaneous 4 Percutaneous
Endoscopic

4 Drug-eluting

Intraluminal Device
D Intraluminal Device
T Radioactive Intraluminal Device
Z No Device

6 Bifurcation

Z No Qualifier


2-Index

(CMS, Development of ICD-10-PCS)
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  • Allows Codes to Be Located Based on an Alphabetic Lookup
  • Codes May Be Found in the Index Based on the General Type of the Procedure
    (e.g., Resection, Transfusion, Fluoroscopy)
    • Or a More Commonly Used Term (e.g., Appendectomy)
  • Code for Percutaneous Intraluminal Dilation of the Coronary Arteries with an Intraluminal
    Device Can Be Found in the Index Under Dilation, or a Synonym of Dilation (e.g., Angioplasty)
  • Once the Desired Term is Located in the Index
    • Index Specifies the First Three or Four Values of the Code(e.g., 027)
    • Or Directs the User to See Another Term
  • Each Table Also Identifies the First Three Values of the Code (e.g., 027)
    • Based on the First Three Values of the Code Obtained From the Index
    • Corresponding Table Can Be Located
  • Table Is Then Used to Obtain the Complete Code by Specifying the Last Four Values


3-List of Codes

(CMS, Development of ICD-10-PCS)
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  • Valid Codes are Constructed
    • Using the First Body Part Value (i.e., One Coronary Artery)
    • Combined with All the Valid Approaches and Devices
      • and the Value No Qualifier
  • Each Code Has a Text Description That Is Complete and Easy to Read
Code Descriptions for Dilation of One Coronary Artery (0270)
027004Z Dilation of Coronary Artery, One Site with Drug-eluting Intraluminal Device, Open Approach
02700DZ Dilation of Coronary Artery, One Site with Intraluminal Device, Open Approach
02700TZ Dilation of Coronary Artery, One Site with Radioactive Intraluminal Device, Open Approach
02700ZZ Dilation, Coronary Artery, One Site, Open Approach
027034Z Dilation, Coronary Artery, One Site with Drug-eluting Intraluminal Device, Percutaneous Approach
02703DZ Dilation, Coronary Artery, One Site with Intraluminal Device, Percutaneous Approach
02703TZ Dilation, Coronary Artery, One Site with Radioactive Intraluminal Device, Percutaneous Approach
02703ZZ Dilation, Coronary Artery, One Site, Percutaneous Approach
027044Z Dilation, Coronary Artery, One Site with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Approach
02704DZ Dilation, Coronary Artery, One Site with Intraluminal Device, Percutaneous Endoscopic Approach
02704TZ Dilation, Coronary Artery, One Site with Radioactive Intraluminal Device, Percutaneous Endoscopic Approach
02704ZZ Dilation, Coronary Artery, One Site, Percutaneous Endoscopic Approach


Alphabetic Index and Tables

(Karla R Lovaasen)
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  • The Seven (7) Characters for Medical and Surgical Procedures Have the Following Meaning:
    • 1. Section
    • 2. Body System
    • 3. Root Operation
    • 4. Body Part
    • 5. Approach
    • 6. Device
    • 7. Qualifier
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ICD-10-PCS Coding Guidelines

(CMS, ICD-10-PCS Official Guidelines for Coding and Reporting-2013)
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A. Conventions

A1

  • Codes Are Composed of Seven (7) Characters
  • Each Character is an Axis of Classification
    That Specifies Information About the Procedure Performed
  • Within a Defined Code Range,
    a Character Specifies the Same Type of Information in That Axis of Classification
  • Example: The 5th Axis of Classification Specifies
    the Approach in Sections 0-4 and 7-9 of the System


A2

  • One of 34 Possible Values Can Be Assigned to Each Axis of Classification
    in the Seven (7) Character Code:
  • Numbers 0-9
  • Alphabet (Except I and O)
  • Number of Unique Values Used in an Axis of Classification Differs as Needed
  • Example: Where the 5th Axis of Classification Specifies the Approach,
    Seven Different Approach Values Are Currently Used to Specify the Approach


A3

  • Valid Values for an Axis of Classification Can Be Added to as Needed
  • Example: If a Significantly Distinct Type of Device Is Used in a New Procedure,
    a New Device Value Can Be Added to the System


A4

  • As with Words in Their Context, the Meaning of Any Single Value Is
    • Combination of Its Axis of Classification
    • and Any Preceding Values on Which It May Be Dependent
  • Example: The Meaning of a Body Part Value in the Medical and Surgical Section
    is Always Dependent on the Body System Value
    • Body Part Value 0 in the Central Nervous Body System Specifies Brain
    • and the Body Part Value 0 in the Peripheral Nervous Body System
      Specifies Cervical Plexus


A5

  • As the System is Expanded to Become Increasingly Detailed,
    Over Time More Values Will Depend on Preceding Values for Their Meaning
  • Example: In the Lower Joints Body System, the Device Value 3 in the Root Operation Insertion Specifies Infusion Device
    and the Device Value 3 in the Root Operation Replacement
    Specifies Ceramic Synthetic Substitute


A6

  • The Purpose of the Alphabetic Index is to Locate the Appropriate Table That Contains All Information Necessary to Construct a Procedure Code
  • PCS Tables Should ALWAYS Be Consulted to Find the Most Appropriate Valid Code


A7

  • It is NOT Required to Consult the Index First
    Before Proceeding to the Tables to Complete the Code
  • Valid Code May Be Chosen Directly From the Tables


A8

  • All Seven (7) Characters MUST Be Specified to Be a Valid Code
  • If Documentation Is Incomplete for Coding Purposes
    • Query Physician


A9

  • Within a PCS Table, Valid Codes Include
    All Combinations of Choices in Characters 4-7 Contained in the Same Row of the Table
  • Example: 0JHT3VZ Is a Valid Code, and 0JHW3VZ Is NOT a Valid Code
Section: 0 Medical and Surgical
Body System: J Subcutaneous Tissue and Fascia
Operation: H Insertion:

Putting in Nonbiological Appliance That Monitors, Assists, Performs, or Prevents
a Physiological Function but Does NOT Physically Take the Place of a Body Part


Body Part Approach Device Qualifier
S Subcutaneous Tissue and Fascia, Head and Neck

V Subcutaneous Tissue and Fascia, Upper Extremity
W Subcutaneous Tissue and Fascia, Lower Extremity

0 Open

3 Percutaneous

1 Radioactive Element

3 Infusion Device

Z No Qualifier
T Subcutaneous Tissue and Fascia, Trunk 0 Open

3 Percutaneous

1 Radioactive Element

3 Infusion Device
V Infusion Pump

Z No Qualifier


A10

  • And When Used in a Code Description, Means And/Or
  • Example: Lower Arm and Wrist Muscle Means Lower Arm And/Or Wrist Muscle


A11

  • Many of the Terms Used to Construct PCS Codes Are Defined Within the System
  • It Is the Coder’s Responsibility to
    Determine What the Documentation in the Medical Record Equates to in the PCS Definitions
  • Physician is NOT Expected to Use the Terms Used in PCS Code Descriptions,
    NOR is the Coder Required to Query the Physician
    When the Correlation Between the Documentation and the Defined PCS Terms is Clear
  • Example: When the Physician Documents Partial Resection the Coder Can Independently Correlate Partial Resection to the Root Operation Excision Without Querying the Physician for Clarification




B. (0) Medical and Surgical Section Guidelines (Section 0)

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B2. Body System (Medical and Surgical Section 0)

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B2.1 General Guidelines-Body System (Medical and Surgical Section 0)

B2.1a
  • Procedure Codes in the Anatomical Regions, General-Body System
    Should ONLY Be Used When the Procedure
    is Performed on an Anatomical Region Rather Than a Specific Body Part
    (e.g., Root Operations-Control and Detachment, Drainage of a Body Cavity)
  • Or on the Rare Occasion When No Information Is Available
    to Support Assignment of a Code to a Specific Body Part
  • Example: Control of Postoperative Hemorrhage is Coded to the Root Operation Control
    Found in the Anatomical Regions, General-Body System


B2.1b
  • Where the General Body Part Values Upper and Lower are Provided as an Option in the
    • Body Systems
      • Above Diaphragm
        • Upper Arteries
        • Upper Veins
        • Muscles and Tendons
      • Below Diaphragm
        • Lower Arteries
        • Lower Veins
        • Muscles and Tendons
  • Example: Vein Body Parts Above the Diaphragm Are Found in the Upper Veins-Body System;

Vein Body Parts Below the Diaphragm Are Found in the Lower Veins-Body System




B3. Root Operation (Medical and Surgical Section 0)

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B3.1 General Guidelines-Root Operation (Medical and Surgical Section 0)

B3.1a
  • In Order to Determine the Appropriate Root Operation,
    the Full Definition of the Root Operation as Contained in the PCS Tables Must Be Applied
B3.1b
  • Components of a Procedure Specified
    in the Root Operation Definition and Explanation Are NOT Coded Separately
  • Procedural Steps Necessary to Reach the Operative Site and Close the Operative Site,
    Including Anastomosis of a Tubular Body Part,
    NOT Coded Separately
  • Example: Resection of a Joint as Part of a Joint Replacement Procedure is Included in the
    Root Operation Definition of Replacement and is NOT Coded Separately
  • Laparotomy Performed to Reach the Site of an Open Liver Biopsy is
    NOT Coded Separately
  • In a Resection of Sigmoid Colon with Anastomosis of Descending Colon to Rectum,
    the Anastomosis Is NOT Coded Separately


B3.2 Multiple Procedures-Root Operation (Medical and Surgical Section 0) B3.2

  • During the Same Operative Episode, Multiple Procedures Are Coded if:
B3.2a. Same Root Operation is Performed on Different Body Parts
  • as Defined by Distinct Values of the Body Part Character
  • Example: Diagnostic Excision of Liver and Pancreas Are Coded Separately
B3.2b. Same Root Operation is Repeated at Different Body Sites
  • That are Included in the Same Body Part Value
  • Example: Excision of the Sartorius Muscle and Excision of the Gracilis Muscle
    are Both Included in the Upper Leg Muscle Body Part Value, and
    Multiple Procedures are Coded
B3.2c. Multiple Root Operations with Distinct Objectives are Performed on the Same Body Part
  • Example: Destruction of Sigmoid Lesion and Bypass of Sigmoid Colon
    are Coded Separately
B3.2d. Intended Root Operation is Attempted Using One Approach, but Is Converted to a Different Approach
  • Example: Laparoscopic Cholecystectomy Converted to an Open Cholecystectomy is Coded as Percutaneous Endoscopic
    Inspection and Open Resection


B3.3 Discontinued Procedures-Root Operation (Medical and Surgical Section 0)

  • If the Intended Procedure is Discontinued,
  • Code the Procedure to the Root Operation Performed
  • If a Procedure is Discontinued Before Any Other Root Operation is Performed,
  • Code the Root Operation-Inspection of the Body Part or Anatomical Region Inspected
  • Example: A Planned Aortic Valve Replacement Procedure is Discontinued
    After the Initial Thoracotomy and Before Any Incision Is Made in the Heart Muscle,
    When the Patient Becomes Hemodynamically Unstable
  • This Procedure Is Coded as an Open Inspection of the Mediastinum


B3.4 Biopsy Followed by More Definitive Treatment-Root Operation (Medical and Surgical Section 0)

  • If a Diagnostic Excision, Extraction, or Drainage Procedure (Biopsy) is
    Followed by a More Definitive Procedure, Such as Destruction, Excision or Resection
    at the Same Procedure Site, Both the Biopsy and the More Definitive Treatment Are Coded
  • Example: Biopsy of Breast Followed by Partial Mastectomy at the Same Procedure Site,
    Both the Biopsy and the Partial Mastectomy Procedure Are Coded


B3.5 Overlapping Body Layers-Root Operation (Medical and Surgical Section 0)

  • If the Root Operations Excision, Repair or Inspection Are Performed
    on Overlapping Layers of the Musculoskeletal System
    • Body Part Specifying the Deepest Layer Is Coded
  • Example: Excisional Debridement That Includes Skin and Subcutaneous Tissue and Muscle
    is Coded to the Muscle Body Part


B3.6 Bypass Procedures-Root Operation (Medical and Surgical Section 0)

B3.6a
  • Bypass Procedures Are Coded by Identifying
    • Body Part Bypassed From (Character 4)
    • and Body Part Bypassed To (Qualifier)
  • Example: Bypass From Stomach to Jejunum,
    Stomach is the Body Part and Jejunum is the Qualifier


B3.6b
  • Coronary Arteries Are Classified by Number of Distinct Sites Treated,
    Rather Than Number of Coronary Arteries or Anatomic Name of a Coronary Artery
    (e.g., Left Anterior Descending)
  • Coronary Artery Bypass Procedures are Coded Differently
    Than Other Bypass Procedures as Described in the Previous Guideline
  • Rather Than Identifying the Body Part Bypassed From
    • Body Part Identifies the Number of Coronary Artery Sites Bypassed To
    • and the Qualifier Specifies the Vessel Bypassed From
  • Example: Aortocoronary Artery Bypass of One Site
    on the Left Anterior Descending Coronary Artery
    and One Site on the Obtuse Marginal Coronary Artery
  • is Classified in the Body Part Axis of Classification
    as Two Coronary Artery Sites
    and the Qualifier Specifies the Aorta as the Body Part Bypassed From


B3.6c
  • If Multiple Coronary Artery Sites are Bypassed
    • Separate Procedure is Coded for Each Coronary Artery Site
      That Uses a Different Device and/or Qualifier
  • Example: Aortocoronary Artery Bypass and Internal Mammary Coronary Artery Bypass
    are Coded Separately


B3.7 Control vs. More Definitive Root Operations-Root Operation (Medical and Surgical Section 0)

  • If Root Operation-Control is Defined as,
    Stopping, or Attempting to Stop, Postprocedural Bleeding
  • If an Attempt to Stop Postprocedural Bleeding
    is Initially Unsuccessful,
    and to Stop the Bleeding Requires Performing
    Any of the Definitive Root Operations
    • Bypass
    • Detachment
    • Excision
    • Extraction
    • Reposition
    • Replacement
    • or Resection
    • Then That Root Operation is Coded Instead of Control
  • Example: Resection of Spleen to Stop Postprocedural Bleeding
    is Coded to Resection Instead of Control


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B3.8 Excision vs. Resection-Root Operation (Medical and Surgical Section 0)

  • PCS Contains Specific Body Parts for Anatomical Subdivisions of a Body Part,
    Such as Lobes of the Lungs or Liver and Regions of the Intestine
  • Resection of the Specific Body Part
    • Coded Whenever All of the Body Part is Cut Out or Off,
      Rather Than Coding Excision of a Less Specific Body Part
  • Example: Left Upper Lung Lobectomy Is Coded to Resection of Upper Lung Lobe, Left
    Rather Than Excision of Lung, Left


B3.9 Excision for Graft-Root Operation (Medical and Surgical Section 0)

  • If an Autograft is Obtained from a Different Body Part
    in Order to Complete the Objective of the Procedure
    • Separate Procedure Is Coded
  • Example: Coronary Bypass with Excision of Saphenous Vein Graft,
    Excision of Saphenous Vein is Coded Separately


B3.10 Fusion Procedures of the Spine-Root Operation (Medical and Surgical Section 0)

B3.10a
  • Body Part Coded for a Spinal Vertebral Joint(s)
    Rendered Immobile by a Spinal Fusion Procedure
    • Classified by the Level of the Spine (e.g. Thoracic)
  • There are Distinct Body Part Values for a Single Vertebral Joint
    and for Multiple Vertebral Joints at Each Spinal Level
  • Example: Body Part Values Specify Lumbar Vertebral Joint, Lumbar Vertebral Joints,
    2 or More and Lumbosacral Vertebral Joint


B3.10b
  • If Multiple Vertebral Joints are Fused
    • Separate Procedure Coded
      for Each Vertebral Joint That Uses a Different Device and/or Qualifier
  • Example: Fusion of Lumbar Vertebral Joint, Posterior Approach, Anterior Column
    and Fusion of Lumbar Vertebral Joint, Posterior Approach, Posterior Column
    are Coded Separately


B3.10c
  • Combinations of Devices and Materials are Often Used on a Vertebral Joint
    to Render the Joint Immobile
  • When Combinations of Devices are Used on the Same Vertebral Joint,
    the Device Value Coded for the Procedure is as Follows:
    • If an Interbody Fusion Device is Used to Render the Joint Immobile
      (Alone or Containing Other Material Like Bone Graft),
      the Procedure is Coded with the Device-Interbody Fusion Device
    • if Bone Graft is the Only Device Used to Render the Joint Immobile,
      the Procedure is Coded with the
      Device-Nonautologous Tissue Substitute or Autologous Tissue Substitute
    • If a Mixture of Autologous and Nonautologous Bone Graft
      (with or Without Biological or Synthetic Extenders or Binders)
      is Used to Render the Joint Immobile,
      Code the Procedure with the Device-Autologous Tissue Substitute
  • Examples: Fusion of a Vertebral Joint Using a Cage Style Interbody Fusion Device
    Containing Morsellized Bone Graft Is Coded to the Device-Interbody Fusion Device
  • Fusion of a Vertebral Joint Using a Bone Dowel Interbody Fusion Device Made of Cadaver Bone
    and Packed with a Mixture of Local Morsellized Bone and Demineralized Bone Matrix
    is Coded to the Device-Interbody Fusion Device
  • Fusion of a Vertebral Joint Using Both Autologous Bone Graft and Bone Bank Bone Graft
    is Coded to the Device-Autologous Tissue Substitute


B3.11 Inspection Procedures-Root Operation (Medical and Surgical Section 0)

B3.11a
  • Inspection of Body Part(s) Performed in Order
    to Achieve the Objective of a Procedure is NOT Coded Separately
  • Example: Fiberoptic Bronchoscopy Performed for Irrigation of Bronchus,
    Only the Irrigation Procedure Is Coded


B3.11b
  • If Multiple Tubular Body Parts are Inspected,
    the Most Distal Body Part Inspected Is Coded
  • If Multiple Non-Tubular Body Parts in a Region are Inspected,
    the Body Part that Specifies the Entire Area Inspected is Coded
  • Examples: Cystoureteroscopy with Inspection of Bladder and Ureters
    is Coded to the Ureter Body Part Value
  • Exploratory Laparotomy with General Inspection of Abdominal Contents
    is Coded to the Peritoneal Cavity Body Part Value


B3.11c
  • When Both an Inspection Procedure and Another Procedure
    are Performed on the Same Body Part During the Same Episode,
    if Inspection Procedure is Performed Using a Different Approach Than the Other Procedure,
    the Inspection Procedure Is Coded Separately
  • Example: Endoscopic Inspection of the Duodenum
    is Coded Separately
    When Open Excision of the Duodenum is Performed During the Same Procedural Episode


B3.12 Occlusion vs. Restriction for Vessel Embolization Procedures-Root Operation (Medical and Surgical Section 0)

  • If the Objective of an Embolization Procedure
    is to Completely Close a Vessel, the Root Operation-Occlusion is Coded
  • If the Objective of an Embolization Procedure
    is to Narrow the Lumen of a Vessel, *:the Root Operation-Restriction is Coded
  • Examples: Tumor Embolization is Coded to the Root Operation-Occlusion,
    Because the Objective of the Procedure is to Cut Off the Blood Supply to the Vessel
  • Embolization of a Cerebral Aneurysm is Coded to the Root Operation-Restriction,
    Because the Objective of the Procedure Is NOT to Close Off the Vessel Entirely,
    but to Narrow the Lumen of the Vessel at the Site of the Aneurysm Where It is Abnormally Wide


B3.13 Release Procedures-Root Operation (Medical and Surgical Section 0)

  • In the Root Operation-Release, the Body Part Value Coded is the Body Part Being Freed
    and NOT the Tissue Being Manipulated or Cut to Free the Body Part
  • Example: Lysis of Intestinal Adhesions is Coded to the Specific Intestine Body Part Value


B3.14 Release vs. Division-Root Operation (Medical and Surgical Section 0)

  • If the Sole Objective of the Procedure is
    Freeing a Body Part Without Cutting the Body Part, the Root Operation-Release
  • If the Sole Objective of the Procedure is
    Separating or Transecting a Body Part, the Root Operation-Division
  • Examples: Freeing a Nerve Root from Surrounding Scar Tissue to Relieve Pain
    is Coded to the Root Operation-Release
  • Severing a Nerve Root to Relieve Pain is Coded to the Root Operation-Division


B3.15 Reposition for Fracture Treatment-Root Operation (Medical and Surgical Section 0)

  • Reduction of a Displaced Fracture is Coded to the Root Operation-Reposition
    and the Application of a Cast or Splint in Conjunction with the Reposition Procedure
    is NOT Coded Separately
  • Treatment of a Nondisplaced Fracture is Coded to the Procedure Performed
  • Examples: Putting a Pin in a Nondisplaced Fracture is Coded to the Root Operation-Insertion
  • Casting of a Nondisplaced Fracture
    is Coded to the Root Operation-Immobilization in the Placement Section


B3.16 Transplantation vs. Administration-Root Operation (Medical and Surgical Section 0)

  • Putting in Mature and Functioning Living Body Part<u> Taken <u>from Another Individual or Animal
    • Coded to the Root Operation-Transplantation
  • Putting in Autologous or Nonautologous Cells
    • Coded to the Administration Section
  • Example: Putting in Autologous or Nonautologous Bone Marrow, Pancreatic Islet Cells
    or Stem Cells is Coded to the Administration Section



B4. Body Part (Medical and Surgical Section 0)

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B4.1 General Guidelines-Body Part (Medical and Surgical Section 0)

B4.1a
  • If a Procedure is Performed on a
    Portion of a Body Part That Does NOT Have a Separate Body Part Value
    • Code the Body Part Value Corresponding to the Whole Body Part
  • Example: Procedure Performed on the Alveolar Process of the Mandible
    is Coded to the Body Part-Mandible


B4.1b
  • If the Prefix Peri is Combined with a Body Part to Identify the Site of the Procedure,
    the Procedure is Coded to the Body Part Named
  • Example: Procedure Site Identified as Perirenal is Coded to the Kidney Body Part


B4.2 Branches of Body Parts-Body Part (Medical and Surgical Section 0)

  • Where a Specific Branch of a Body Part Does NOT Have its Own Body Part Value,
    the Body Part is Coded to the Closest Proximal Branch That Has a Specific Body Part Value
  • Example: Procedure Performed on the Mandibular Branch of the Trigeminal Nerve
    is Coded to Body Part-Trigeminal Nerve


B4.3 Bilateral Body Part Values-Body Part (Medical and Surgical Section 0)

  • Bilateral Body Part Values are Available for a Limited Number of Body Parts
  • If the Identical Procedure is Performed on Contralateral Body Parts,
    and a Bilateral Body Part Value Exists for that Body Part,
    • Single Procedure is Coded Using the Bilateral Body Part Value
  • If NO Bilateral Body Part Value Exists,
    Each Procedure is Coded Separately Using the Appropriate Body Part Value


B4.4 Coronary Arteries-Body Part (Medical and Surgical Section 0)

  • Classified as a Single Body Part That is
    Further Specified by Number of Sites Treated and NOT by Name or Number of Arteries
  • Separate Body Part Values are Used to Specify the Number of Sites Treated
    When the Same Procedure is Performed on Multiple Sites in the Coronary Arteries
  • Examples: Angioplasty of Two Distinct Sites in the Left Anterior Descending Coronary Artery with Placement of Two Stents
    is Coded as Dilation of Coronary Arteries, Two Sites, with Intraluminal Device
  • Angioplasty of Two Distinct Sites in the Left Anterior Descending Coronary Artery, One with Stent Placed and One Without,
    is Coded Separately as Dilation of Coronary Artery, One Site with Intraluminal Device, and Dilation of Coronary *:Artery, One Site with No Device


B4.5 Tendons, Ligaments, Bursae and Fascia Near a Joint-Body Part (Medical and Surgical Section 0)

  • Procedures Performed on Tendons, Ligaments, Bursae and Fascia Supporting a Joint are
    Coded to the Body Part in the Respective Body System That Is the Focus of the Procedure
  • Procedures Performed on Joint Structures Themselves are
    Coded to the Body Part in the Joint Body Systems
  • Example: Repair of the Anterior Cruciate Ligament of the Knee
    is Coded to the Knee Bursae and Ligament Body Part in the Bursae and Ligaments Body System
    • Knee Arthroscopy with Shaving of Articular Cartilage
      is Coded to the Knee Joint Body Part in the Lower Joints Body System


B4.6 Skin, Subcutaneous Tissue and Fascia Overlying a Joint-Body Part (Medical and Surgical Section 0)

  • Procedure is Performed on the Skin, Subcutaneous Tissue or Fascia Overlying a Joint,
    the Procedure is Coded to the Following Body Part:
Shoulder Upper Arm
Elbow Lower Arm
Wrist Lower Arm
Hip Upper Leg
Knee Lower Leg
Ankle Foot


B4.7 Fingers and Toes-Body Part (Medical and Surgical Section 0)

  • If a Body System Does NOT Contain a Separate Body Part Value for Fingers,
    Procedures Performed on the Fingers Are Coded to the Body Part Value for the Hand
  • If a Body System Does NOT Contain a Separate Body Part Value for Toes,
    Procedures Performed on the Toes Are Coded to the Body Part Value for the Foot
  • Example: Excision of Finger Muscle
    is Coded to One of the Hand Muscle Body Part Values in the Muscles Body System


B4.8

  • In the Gastrointestinal-Body System, the General Body Part Values
    Upper Intestinal Tract and Lower Intestinal Tract are Provided as an Option for the
    Root Operations-</u>Change, Inspection, Removal and Revision</u>
  • Upper Intestinal Tract Includes the Portion of the Gastrointestinal Tract
    • From the Esophagus
    • Down To and Including the Duodenum
  • Lower Intestinal Tract Includes the Portion of the Gastrointestinal Tract
    • From the Jejunum
    • Down To and Including the Rectum and Anus
  • Example: In the Root Operation Change Table, Change of a Device in the Jejunum
    is Coded Using the Body Part-Lower Intestinal Tract



B5. Approach (Medical and Surgical Section 0)

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(0)  2   3   4   5   6   7 

B5.2 Open Approach with Percutaneous Endoscopic Assistance-Approach (Medical and Surgical Section 0)

  • Open Approach with Percutaneous Endoscopic Assistance
    • Coded to the Approach-Open
  • Example: Laparoscopic-Assisted Sigmoidectomy is Coded to the Approach-Open


B5.3 External Approach-Approach (Medical and Surgical Section 0)

B5.3a
  • Procedures Performed
    Within Orifice on Structures That Are Visible Without the Aid of Any Instrumentation
    • Coded to the Approach-External
  • Example: Resection of Tonsils is Coded to the Approach External


B5.3b
  • Procedures Performed
    Indirectly by the Application of External Force Through the Intervening Body Layers
    • Coded to the Approach-External
  • Example: Closed Reduction of Fracture is Coded to the Approach-External


B5.4 Percutaneous Procedure via Device-Approach (Medical and Surgical Section 0)

  • Procedures Performed
    Percutaneously via a Device Placed for the Procedure
    • Coded to the Approach-Percutaneous
  • Example: Fragmentation of Kidney Stone Performed Via Percutaneous Nephrostomy
    is Coded to the Approach-Percutaneous




B6. Device (Medical and Surgical Section 0)

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(0)  2   3   4   5   6   7 

B6.1 General Guidelines-Device (Medical and Surgical Section 0)

B6.1a
  • Device is Coded ONLY if a Device Remains After the Procedure is Completed
  • If NO Device Remains
    • Device<u>-<u>No Device Is Coded
B6.1b
  • Materials Such as Sutures, Ligatures, Radiological Markers and Temporary Post-Operative Wound Drains are Considered Integral to the Performance of a Procedure
    • NOT Coded as Devices
B6.1c
  • Procedures Performed on a Device ONLY and NOT on a Body Part
    are Specified in the Root Operations-Change, Irrigation, Removal and Revision
    • Coded to the Procedure Performed
  • Example: Irrigation of Percutaneous Nephrostomy Tube
    Is Coded to the Root Operation-Irrigation of Indwelling Device in the Administration Section


B6.2 Drainage Device-Device (Medical and Surgical Section 0)

  • Separate Procedure to Put in a Drainage Device
    • Coded to the Root Operation-Drainage
    • Device-Drainage Device





C. (1) Obstetrics Section Guidelines (Section 1) Obstetrics Section

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(1)  2   3   4   5   6   7 

C1 Products of Conception (Obstetrics Section 1)

  • Procedures Performed on the Products of Conception
    • Coded to the Obstetrics Section
  • Procedures Performed on the Pregnant Female Other Than the Products of Conception
    • Coded to the Appropriate Root Operation in the Medical and Surgical Section
  • Example: Amniocentesis is Coded to the
    Products of Conception Body Part in the Obstetrics Section
    • Repair of Obstetric Urethral Laceration
      is Coded to the Urethra-Body Part in the Medical and Surgical Section


C2 Procedures Following Delivery or Abortion (Obstetrics Section 1)

  • Procedures Performed
    Following a Delivery or Abortion for Curettage of the Endometrium
    or Evacuation of Retained Products of Conception
    • Coded in the Obstetrics Section, to the Root Operation-Extraction and the
      Body Part-Products of Conception, Retained. Diagnostic or Therapeutic Dilation
  • Curettage Performed During Times Other Than the Postpartum or Post-Abortion Period
    • Coded in the Medical and Surgical Section,
      to the Root Operation-Extraction
      and the Body Part-Endometrium




(0) Overview-Medical and Surgical Section

(CMS, Development of ICD-10-PCS)
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(0)  2   3   4   5   6   7 


Medical and Surgical Section Principles (Section 0)

(CMS, Development of ICD-10-PCS)
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  • Composite Terms are NOT Root Operations
    • Only Component of a Procedure Specified in the Root Operation
      is the Objective of the Procedure
    • Composite Terms Such as Colonoscopy and Sigmoidectomy
      are NOT Root Operations Because They Specify Multiple Components of a Procedure
    • Colonoscopy is a Composite of Information Contained in the
      Root Operation Value, i.e., Inspection,
      the Body Part Value, i.e., Large Intestine,
      and the Endoscopic Approach Value, i.e., Via Natural or Artificial Opening Endoscopic
    • Components of a Procedure are Defined Separately
    • Underlying Objective of the Procedure Is Specified by the
      Root Operation (3rd Character),
      Precise Part of the Gastrointestinal Tract Inspected
      is Specified by the Body Part (4th Character),
      and the Method Used to Reach and Visualize the Procedure Site
      is Specified by the Approach (5th Character)
    • Partial Sigmoidectomy is a Composite of Information Contained in the
      Root Operation Value, i.e., Excision,
      and the Body Part Value, i.e., Sigmoid Colon
      • Coded as Excision
        (Cutting Out or Off, Without Replacement, a Portion of a Body Part)
        of the Sigmoid Body Part
    • Terms Colonoscopy and Sigmoidectomy are Listed in the Index,
      They Do NOT Constitute Separate Root Operations in the Tables,
      but Instead Refer to the Correct Root Operation and Body System in the Tables
  • The Root Operation is Based on the Objective of the Procedure
    • Root Operation is Based on the Objective of the Procedure
      • Such as Resection of Transverse Colon
      • or Dilation of an Artery
    • Assignment of the Root Operation is Based on the Procedure Actually Performed,
      • Which May or May Not Have Been the Intended Procedure
    • If the Intended Procedure is Modified or Discontinued
      (e.g., Excision Instead of Resection is Performed), the
      Root Operation is Determined by the Procedure Actually Performed
    • If the Desired Result Fails to Persist After Completion of the Procedure
      (i.e., Artery Does NOT Remain Expanded After the Dilation Procedure), the
      Root Operation is Still Determined by the Procedure Actually Performed
    • If the Procedure Performed Takes Out a Foreign Body
      • Procedure Coded to the Extirpation
    • Dilating the Urethra
      • Coded as Dilation
      • Since the Objective of the Procedure is to Dilate the Urethra
    • If Dilation of the Urethra Includes Putting in an Intraluminal Stent
      • Root Operation Remains Dilation and NOT Insertion of the Intraluminal Device
        • Because the Underlying Objective of the Procedure
          is Dilation of the Urethra
        • Stent is Identified by the Intraluminal Device Value in the
          6th Character of the Dilation Procedure Code
    • If the Objective is Solely to Put a Radioactive Element in the Urethra
      • Procedure is Coded to the Root Operation-Insertion
      • Radioactive Element Identified in the 6th Character of the Code
    • If the Objective of the Procedure is to Correct a Malfunctioning or Displaced Device
      • Procedure is Coded to the Root Operation-Revision
        • Original Device Being Revised is Identified in the Device Character
        • Revision is Typically Performed on Mechanical Appliances
          (e.g., Pacemaker),
          or Materials Used in Replacement Procedures
          (e.g., Synthetic Substitute)
        • Typical Revision Procedures Include
          • Adjustment of Pacemaker Position
          • Correction of Malfunctioning Knee Prosthesis
  • Combination Procedures are Coded Separately
    • If Multiple Procedures as Defined by Distinct Objectives
      Are Performed During an Operative Episode
      • Multiple Codes Are Used
    • For Example, Obtaining the Vein Graft Used for Coronary Bypass Surgery
      • Coded as a Separate Procedure From the Bypass Itself
  • Redo of Procedures are Coded to the Procedure Performed
    • Complete or Partial Redo of the Original Procedure
      • Coded to the Root Operation
        That Identifies the Procedure Performed Rather than Revision
    • For Example, a Complete Redo of a Hip Replacement Procedure
      Which Requires Putting in a New Prosthesis
      • Coded to the Root Operation-Replacement
      • Rather Than Revision
    • Correction of Complications
      Arising from the Original Procedure Other Than Device Complications as Defined in the Root Operation-Revision are **:Also Coded to the Procedure Performed
      • For Example, a Procedure
        to Control Hemorrhage Arising From the Original Procedure
        • Coded to Control Rather than Revision


2-Body System-Medical and Surgical Section 0

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(0)  2   3   4   5   6   7 


Body Systems
(Medical and Surgical Section 0)
0 Central Nervous System (CNS)
1 Peripheral Nervous System (PNS)
2 Heart and Great Vessels
3 Upper Arteries
4 Lower Arteries
5 Upper Veins
6 Lower Veins
7 Lymphatic and Hemic System
8 Eye
9 Ear, Nose, Sinus
B Respiratory System
C Mouth and Throat
F Hepatobiliary System and Pancreas
G Endocrine System
H Skin and Breast
J Subcutaneous Tissue and Fascia
K Muscles
L Tendons
M Bursae and Ligaments
N Head and Facial Bones
P Upper Bones
Q Lower Bones
R Upper Joints
S Lower Joints
T Urinary System
U Female Reproductive System
V Male Reproductive System
W Anatomical Regions, General
X Anatomical Regions, Upper Extremities
Y Anatomical Regions, Lower Extremities


3-Root Operation-Medical and Surgical Section 0

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(0)  2   3   4   5   6   7 


  • x31
Root Operations, Grouped
(Medical and Surgical Section 0)
Remove Some/All of Body Part
(5) Destruction
(6) Detachment
(B) Excision
(D) Extraction
(T) Resection
Remove Solid, Fluids, Gases from a Body Part
(9) Drainage
(C) Extirpation
(F) Fragmentation
Involve Cutting or Separation ONLY
(8) Division
(N) Release
Put In, Put Back, Move Some or All of a Body Part
(M) Reattachment
(S) Reposition
(X) Transfer
hcpro.com
(Fasciocutaneous Flap Closure)
(Musculocutaneous Flap Transfer)
(Transfer Left Abdomen Muscle, Transverse Rectus Abdominis Myocutaneous Flap)
(Y) Transplantation
Alter Diameter/Route of a Tubular Body Part
(I) Bypass
(7) Dilation
(L) Occlusion
(V) Restriction
Involve a Device
(2) Change
(H) Insertion
(R) Replacement
(Replacement of Bilateral Breast using Transverse Rectus Abdominis Myocutaneous Flap)
(P) Removal
(W) Revision
(U) Supplement
Examination Only
(J) Inspection
(K) Map
OTHER Repair
(3) Control
(Q) Repair
OTHER Objectives
(0) Alteration
(4) Creation
(G) Fusion


Root Operations (Medical and Surgical Section 0)
Root Operation Definition
Alteration Modifying the Anatomic Structure of a Body Part Without Affecting the Function of the Body Part
Bypass Altering the Route of Passage of the Contents of a Tubular Body Part
Change Taking Out or Off a Device From a Body Part and Putting Back an Identical or Similar Device in or on the Same Body Part Without Cutting or Puncturing the Skin or a Mucous Membrane
Control Stopping, or Attempting to Stop, Postprocedural Bleeding
Creation Making a New Genital Structure That Does Not Take Over the Function of a Body Part
Destruction Physical Eradication of All or a Portion of a Body Part by the Direct Use of Energy, Force or a Destructive Agent
Detachment Cutting Off All or Part of the Upper or Lower Extremities
Dilation Expanding an Orifice or the Lumen of a Tubular Body Part
Division Cutting Into a Body Part Without Draining Fluids and/or Gases from the Body Part in Order to Separate or Transect a Body Part
Drainage Taking or Letting Out Fluids and/or Gases from a Body Part
Excision Cutting Out or Off, Without Replacement, a Portion of a Body Part
Extirpation Taking or Cutting Out Solid Matter From a Body Part
Extraction Pulling or Stripping Out or Off All or a Portion of a Body Part by the Use of Force
Fragmentation Breaking Solid Matter in a Body Part Into Pieces
Fusion Joining Together Portions of an Articular Body Part Rendering the Articular Body Part Immobile
Insertion Putting in a Non-Biological Appliance That Monitors, Assists, Performs or Prevents a Physiological Function but Does NOT Physically Take the Place of a Body Part
Inspection Visually and/or Manually Exploring a Body Part
Map Locating the Route of Passage of Electrical Impulses and/or Locating Functional Areas in a Body Part
Occlusion Completely Closing an Orifice or the Lumen of a Tubular Body Part
Reattachment Putting Back in or on All or a Portion of a Separated Body Part to Its Normal Location or Other Suitable Location
Release Freeing a Body Part From an Abnormal Physical Constraint by Cutting or by Use of Force
Removal Taking Out or Off a Device From a Body Part
Repair Restoring, to the Extent Possible, a Body Part to Its Normal Anatomic Structure and Function
Replacement Putting in or on Biological or Synthetic Material That Physically Takes the Place and/or Function of All or a Portion of a Body Part
Reposition Moving to Its Normal Location or Other Suitable Location All or a Portion of a Body Part
Resection Cutting Out or Off, Without Replacement, All of a Body Part
Restriction Partially Closing an Orifice or the Lumen of a Tubular Body Part
Revision Correcting, to the Extent Possible, a Portion of a Malfunctioning Device or the Position of a Displaced Device
Supplement Putting in or on Biological or Synthetic Material That Physically Reinforces and/or Augments the Function of a Body Part
Transfer Moving, Without Taking Out, All or a Portion of a Body Part to Another Location to Take Over the Function of All or a Portion of a Body Part
Transplantation Putting in or on All or a Portion of a Living Body Part Taken From Another Individual or Animal to Physically Take the Place and/or Function of All or a Portion of a Similar Body Part

4-Body Part-Medical and Surgical Section 0

(0)  2   3   4   5   6   7 
  • x34
  • Body Part Examples
    • Liver
    • Kidney
    • Thalamus
    • Ascending Colon
    • Optic Nerve
    • Tonsil
    •  :



5-Approach-Medical and Surgical Section 0

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(0)  2   3   4   5   6   7 
  • Technique Used to Reach the Site of the Procedure
  • Approaches (x7)
    1. (0) Open
    2. (3) Percutaneous
    3. (4) Percutaneous Endoscopic
    4. (7) Via Natural or Artificial Opening
    5. (8) Via Natural or Artificial Opening Endoscopic
    6. (F) Open with Percutaneous Endoscopic Assistance
    7. (X) External
  • Approach Components : (x3)
    1. Access Location
      • Procedures Performed on an Internal Body Part
      • Access Location Specifies the External Site
        Through Which the Site of the Procedure is Reached
      • General Types of Access Locations: (x2)
        1. Skin or Mucous Membranes
          • Can Be Cut or Punctured to Reach the Procedure Site
        2. External Orifices
      • Every Approach Value Except External
        Includes One of These Two Access Locations
      • All Open and Percutaneous Approach Values Use This Access Location
      • Site of a Procedure Can Also Be Reached Through an External Opening
      • External Openings Can Be
        1. Natural (e.g., Mouth)
        2. Artificial (e.g., Colostomy Stoma)
    2. Method
      • For Procedures Performed on an Internal Body Part
      • Method Specifies How the External Access Location is Entered
      • Open Method Specifies Cutting Through the Skin or Mucous Membrane and Any Other Intervening Body Layers
        Necessary to Expose the Site of the Procedure
      • Instrumental Method Specifies the Entry of Instrumentation
        Through the Access Location to the Internal Procedure Site
      • Instrumentation Can Be Introduced by
        1. Puncture
        2. or Minor Incision
        3. or Through an External Opening
      • Puncture or Minor Incision Does NOT Constitute an Open Approach
        • Because It Does NOT Expose the Site of the Procedure
      • Approach Can Define Multiple Methods
        • For Example, the Percutaneous Endoscopic Approach Includes Both the Percutaneous Method to Reach the Procedure Site
          and the Introduction of Instrumentation Into the Body Part
          to Perform the Procedure
    3. Type of Instrumentation
      • Procedures Performed on an Internal Body Part
      • Instrumentation Means That Specialized Equipment
        is Used to Perform the Procedure
      • Instrumentation is Used in All Internal Approaches
        Other Than the Basic Open Approach
      • Instrumentation May or May Not
        Include the Capacity to Visualize the Procedure Site
      • For Example, the Instrumentation Used to Perform a Sigmoidoscopy Permits the Internal Site of the Procedure to Be Visualized,
        Instrumentation Used to Perform a Needle Biopsy of the Liver Does NOT
      • Term Endoscopic as Used in Approach Values
        Refers to Instrumentation That Permits a Site to Be Visualized
  • External Approaches
    • Procedures Performed Directly on the Skin or Mucous Membrane
      Are Identified by the External Approach (e.g., Skin Excision)
    • Procedures Performed Indirectly by the Application of External Force
      Are Also Identified by the External Approach
      (e.g., Closed Reduction of Fracture)


Approach Definition
(0) Open Cutting Through the Skin or Mucous Membrane and Any Other Body Layers Necessary to Expose the Site of the Procedure
(3) Percutaneous Entry, by Puncture or Minor Incision, of Instrumentation Through the Skin or Mucous Membrane and/or Any Other Body Layers Necessary to Reach the Site of the Procedure

(Pertains to any medical procedure where access to inner organs or other tissue is done via needle-puncture of the skin, rather than by using an Open approach where inner organs or tissue are exposed)

(4) Percutaneous Endoscopic Entry, by Puncture or Minor Incision, of Instrumentation Through the Skin or Mucous Membrane and/or Any Other Body Layers Necessary to Reach and Visualize the Site of the Procedure
(7) Via Natural

or Artificial Opening

Entry of Instrumentation Through a Natural or Artificial External Opening to Reach the Site of the Procedure
(8) Via Natural

or Artificial Opening Endoscopic

Entry of Instrumentation Through a Natural or Artificial External Opening to Reach and Visualize the Site of the Procedure
(F) Via Natural or

Artificial Opening Endoscopic
with Percutaneous Endoscopic Assistance
(Open with Percutaneous Endoscopic Assistance)

Entry of Instrumentation Through a Natural or Artificial External Opening to Reach and Visualize the Site of the Procedure, and Entry, by Puncture or Minor Incision, of Instrumentation Through the Skin or Mucous Membrane and Any Other Body Layers Necessary to Aid in the Performance of the Procedure
(X) External Procedures Performed Directly on the Skin or Mucous Membrane and Procedures Performed Indirectly by the Application of External Force Through the Skin or Mucous Membrane



6-Device-Medical and Surgical Section 0

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(0)  2   3   4   5   6   7 
  • General Types of Devices (x4)
    1. Biological or Synthetic Material that Takes Place of All or Portion of Body Type
      (e.g., Skin Graft, Joint Prosthesis)
    2. Biological or Synthetic Material that Assists or Prevents Physiological Function
      (e.g., IUD)
    3. Therapeutic Material NOT Absorbed by, Eliminated by, or Incorporated into Body Part
      (e.g., Radioactive Implant)
    4. Mechanical or Electronic Appliances Used to Assist, Monitor, Take Place of,
      or Prevent Physiological Function
      (e.g., Cardiac Pacemaker, Orthopedic Pin)
  • All Devices CAN Be Removed
  • Some Devices Cannot Be Removed
    Without Putting in Another Non-Biological Appliance or Body Part Substitute
  • Specific Device Values May Be Coded with Root Operations
    • Alteration
    • Bypass
    • Creation
    • Dilation
    • Drainage
    • Fusion
    • Occlusion
    • Reposition
    • Restriction
  • Specific Device Values Must Be Coded with the Root Operations
    • Change
    • Insertion
    • Removal
    • Replacement
    • Revision
  • Instruments Used to Visualize the Procedure Site
    are NOT Specified in the Device Value
    • This Information Is Specified in the Approach Value
  • If the Objective of the Procedure is to Put in the Device
    • Root Operation-Insertion
  • If the Device is Put in to Meet an Objective Other Than Insertion
    • Root Operation Defining the Underlying Objective of the Procedure is Used,
      with the Device Specified in the Device Character
    • Example: If a Procedure to Replace the Hip Joint is Performed,
      the Root Operation-Replacement is Coded
      and the Prosthetic Device is Specified in the Device Character
  • Materials Incidental to a Procedure Such as Clips, Ligatures and Sutures
    are NOT Specified in the Device Character
  • Because New Devices Can Be Developed
    • Other Device is Provided as a Temporary Option
      for Use Until a Specific Device Value is Added to the System


7-Qualifier-Medical and Surgical Section 0

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(0)  2   3   4   5   6   7 
  • Contains Unique Values for Individual Procedures as Needed
  • For Example, the Qualifier Can Be Used to Identify the Destination Site in a Bypass





(1-H) Overview-Other Medical- and Surgical-Related Procedures

(CMS, Development of ICD-10-PCS)
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(1-H)  2   3   4   5   6   7 


(1) Obstetrics

 1. (1) Section
 2. Body System
 3. Root Operation
    • (A) Abortion
    • (E) Delivery
 4. Body Part
    • Products of Conception
    • Products of Conception, Retained
    • Products of Conception, Ectopic
 5. Approach
 6. Device
 7. Qualifier
    • Type of Extraction
    • Type of Cesarean Section
    •  :

(2) Placement

 • Procedures for Putting a Device In or On a Body Region for
   • Protection
   • Immobilization
   • Stretching
   • Compression
   • Packing

 1. (2) Section
 2. Body System
 3. Root Operation
 4. Body Part
 5. Approach
 6. Device
 7. Qualifier

(3) Administration

 • Procedures for Putting In or On a Substance that is
   • Therapeutic
   • Prophylactic
   • Protective
   • Diagnostic
   • Nutritional
   • Physiological

(4) Measurement and Monitoring

 • Procedures for Determining The Level of a Physiological or Physical Function

(5) Extracorporeal Assistance and Performance

 • Used When Equipment Outside of Body is
    Used to Assist or Perform a Physiological Function

(6) Extracorporeal Therapies

 • Used When Equipment Outside of Body is Used for a Therapeutic Purpose
    that Does NOT Involve the Assistance or Performance of a Physiological Function

(7) Osteopathic
(8) Other Procedures

 • Used for a Variety of Other Procedures
   • Acupuncture
   • Suture Removal
   • In Vitro Fertilization

(9) Chiropractic
 
(B) Imaging

 • Plain Radiology
 • Fluoroscopy
 • Computerized Tomography (CT) Imaging
 • Magnetic Resonance Imaging (MRI)
 • Ultrasound (Ultrasonography)

(C) Nuclear Medicine

 • Planar Imaging
 • Tomographic (Tomo) Imaging
 • Positron Emission Tomographic (PET) Imaging
 • Nonimaging Uptake
 • Nonimaging Probe
 • Nonimaging Assay
 • Systemic Therapy
 • NOT Radiation Therapy

(D) Radiation Oncology

 • Procedures that Introduce Radioactive Material for Cancer Treatment

(F) Physical Rehabilitation and Diagnostic Audiology

 • Physical Therapy (PT)
 • Occupational Therapy (OT)
 • Speech Language Pathology
 • Diagnostic Audiology

(G) Mental Health
 
(H) Substance Abuse Treatment
 

ICD-10-PCS: Guideline Spotlight

(Optum)
TOP

Questions:

  1. A Valid PCS Code Can Be Chosen Directly From the PCS Table
    Without Consulting the Alphabetic Index First.
  2. When Using the PCS Table, Character Values
    May Be Selected From Different Rows of the Same Table to Create a Code.
  3. A Resection of the Sigmoid Colon with Side-to-Side Anastomosis
    Is Reported with Both the Resection and the Anastomosis Codes.
  4. An Attempted Laparoscopic Cholecystectomy Converted to Open
    Is Reported as the Definitive Procedure Only, I.E., Code Only the Open Cholecystectomy.
  5. A Procedure Discontinued Before Any Root Operation Is Performed Is Not Reported.
  6. A Biopsy Followed by Definitive Treatment of the Same Site Is Reported with a Code for the Biopsy and a Code for the Definitive Procedure.
  7. When Coding a Procedure Involving the Musculoskeletal System, the Root Operations Excision, Repair, and Inspection Are Reported with a Code Identifying the Body Part of the Deepest Layer Involved.
  8. Successful Control of Postglossectomy Site Bleeding by Coblation and Electrocautery Is Reported as Destruction of the Site.
  9. Angiojet Thrombectomy and Angioplasty of the Same Vessel Is Reported with Two Codes, One for Each Procedure.
  10. An Arthroscopy Followed by an Open Reduction with Internal Fixation of a Fracture Is Reported with Two Codes,
    One for the Arthroscopy (Inspection) and One for the ORIF.


Answers:

  1. True. Guideline A7 states the index does not need to be used and procedures can be coded directly from the tables.
  2. False. Guideline A9 states that valid codes within the table include all combinations of choices contained in the same row of the table.
  3. False. Guideline B3.1b states procedures to close an operative site, including anastomosis of a tubular body part, are not coded separately.
  4. False. Guideline B3.2 states that if the intended root operation is attempted by one approach but is converted to another, code both the discontinued procedure to the root operation performed and the definitive procedure.
  5. False. Guideline B3.3 states that when a procedure is discontinued before any root operation is performed, report as Inspection of the body part or anatomical region inspected.
  6. True. Guideline B3.4 states that both the biopsy and the definitive treatment are coded.
  7. True. Guideline B3.5 states that for the root operations Excision, Repair, and Inspection with overlapping layers of the musculoskeletal system, only the body part identifying the deepest layer is coded.
  8. False. Guideline B3.7 directs coders to report the root operation Control for successful control of postprocedural bleeding when it does not require any of the root operations of Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection.
  9. True. Guideline B3.2.c states that when multiple root operations with distinct objectives are performed on the same body part, each is coded.
  10. True. Guideline B3.11c states to code both the Inspection and the other procedure when each is performed by different approaches on the same body part.

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