ICD-10-PCS Reference Manual - Find-A-Code

ICD-10-PCS Reference Manual

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Table of Contents

Preface

............................................................................................ xi

Manual organization ................................................................................................................. xi Chapter 1 - Overview ......................................................................................................... xi Chapter 2 - Procedures in the Medical and Surgical section ............................................. xi Chapter 3 - Procedures in the Medical and Surgical-related sections............................... xi Chapter 4 - Procedures in the ancillary sections ...............................................................xii Appendix A - ICD-10-PCS definitions ................................................................................xii Appendix B - ICD-10-PCS device and substance classification ........................................xii

Conventions used .....................................................................................................................xii Root operation descriptions ...............................................................................................xii Table excerpts...................................................................................................................xiii

Chapter 1: ICD-10-PCS overview ......................................................... 15

What is ICD-10-PCS?.............................................................................................................. 15 History of ICD-10-PCS ...................................................................................................... 15 ICD-9-CM Volume 3 compared with ICD-10-PCS ............................................................ 16

ICD-10-PCS code structure ..................................................................................................... 16 Characters ......................................................................................................................... 17 Values ........................................................................................................................... 17 Code structure: Medical and Surgical section................................................................... 17 Character 1: Section ................................................................................................... 18 Character 2: Body system .......................................................................................... 18 Character 3: Root operation ....................................................................................... 18 Character 4: Body part................................................................................................ 19 Character 5: Approach................................................................................................ 19 Character 6: Device .................................................................................................... 20 Character 7: Qualifier.................................................................................................. 20 ICD-10-PCS system organization ..................................................................................... 21 Medical and Surgical section ...................................................................................... 21 Medical and Surgical-related sections........................................................................ 21 Ancillary sections ........................................................................................................ 22 Tables ......................................................................................................................... 23 Index ........................................................................................................................... 24 List of Codes ............................................................................................................... 25

ICD-10-PCS design ................................................................................................................. 26 Multiaxial structure ............................................................................................................ 26 Completeness ................................................................................................................... 27 Coronary bypass example .......................................................................................... 27 Unique definitions ....................................................................................................... 28 Expandability ..................................................................................................................... 28 ICD-10-PCS update: PICVA ....................................................................................... 29 Structural integrity....................................................................................................... 29

ICD-10-PCS additional characteristics .................................................................................... 30 Standardized terminology ................................................................................................. 30 No eponyms or common procedure names ............................................................... 30

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No combination codes ................................................................................................ 31 Standardized level of specificity ........................................................................................ 31 Diagnosis information excluded ........................................................................................ 31 NOS code options restricted ............................................................................................. 32 Limited NEC code options................................................................................................. 32 ICD-10-PCS applications......................................................................................................... 32 Optimal search capability .................................................................................................. 33 Consistent characters and values ..................................................................................... 33 Code readability ................................................................................................................ 34

Chapter 2: Procedures in the Medical and Surgical section ................... 37

Root operation groups ............................................................................................................. 37 Root operations that take out some or all of a body part......................................................... 39

Excision--Root operation B .............................................................................................. 40 Coding note: Bone marrow and endometrial biopsies................................................ 40 Example: Excision of sebaceous cyst (right buttock) ................................................. 40 Coding exercises ........................................................................................................ 41

Resection--Root operation T............................................................................................ 41 Coding note: Lymph nodes......................................................................................... 42 Example: Right hemicolectomy .................................................................................. 42 Coding note: Anastomotic technique.......................................................................... 42 Coding exercises ........................................................................................................ 42

Detachment--Root operation 6......................................................................................... 43 Detachment qualifiers ................................................................................................. 43 Example: Fifth toe ray amputation .............................................................................. 44 Coding exercises ........................................................................................................ 45 Coding note: Qualifier value ....................................................................................... 45

Destruction--Root operation 5.......................................................................................... 45 Example: Radiofrequency coagulation of the trigeminal nerve .................................. 46 Coding note: Approach value ..................................................................................... 46 Coding exercises ........................................................................................................ 46

Extraction--Root operation D ........................................................................................... 47 Example: Suction dilation & curettage........................................................................ 47 Coding exercises ........................................................................................................ 47

Root operations that take out solids/fluids/gases from a body part......................................... 48 Drainage--Root operation 9 ............................................................................................. 49 Example: Urinary nephrostomy catheter placement .................................................. 49 Coding exercises ........................................................................................................ 49 Extirpation--Root operation C .......................................................................................... 50 Example: De-clotting of AV dialysis graft.................................................................... 50 Coding note: body part value...................................................................................... 50 Coding exercises ........................................................................................................ 51 Fragmentation--Root operation F .................................................................................... 51 ESWL of left kidney .................................................................................................... 52 Coding exercises ........................................................................................................ 52

Root operations involving cutting or separation only ............................................................... 52 Division--Root operation 8 ............................................................................................... 53 Example: Anal sphincterotomy ................................................................................... 53 Coding note: Approach value ..................................................................................... 53 Coding exercises ........................................................................................................ 54 Release--Root operation N .............................................................................................. 54

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Example: Release of median nerve............................................................................ 54 Coding note: body part value...................................................................................... 55 Coding exercises ........................................................................................................ 55 Root operations that put in/put back or move some/all of a body part .................................... 56 Transplantation--Root operation Y................................................................................... 56 Example: Right kidney transplant (syngeneic) ........................................................... 57 Coding note: bone marrow transplant ........................................................................ 57 Coding exercises ........................................................................................................ 57 Reattachment--Root operation M..................................................................................... 58 Example: Complex reattachment, left index finger ..................................................... 58 Coding exercises ........................................................................................................ 58 Transfer--Root operation X .............................................................................................. 59 Example: Fasciocutaneous flap from scalp to cheek ................................................. 59 Coding note: body system value ................................................................................ 59 Coding exercises ........................................................................................................ 60 Reposition--Root operation S........................................................................................... 60 Example: Reposition of undescended right testicle from pelvic region to scrotum .... 60 Coding exercises ........................................................................................................ 61 Root operations that alter the diameter/route of a tubular body part....................................... 61 Restriction--Root operation V........................................................................................... 62 Example: Laparoscopic gastroesophageal fundoplication ......................................... 62 Coding exercises ........................................................................................................ 63 Occlusion--Root operation L ............................................................................................ 63 Example: Uterine artery embolization......................................................................... 63 Coding exercises ........................................................................................................ 64 Dilation--Root operation 7 ................................................................................................ 64 Example: PTCA of left anterior descending ............................................................... 65 Coding exercises ........................................................................................................ 65 Bypass--Root operation 1 ................................................................................................ 65 Example: Aorto-bifemoral bypass graft ...................................................................... 66 Coding exercises ........................................................................................................ 66 Root operations that always involve a device ......................................................................... 67 Insertion--Root operation H.............................................................................................. 68 Example: Port-a-cath placement ................................................................................ 68 Coding note: imaging guidance .................................................................................. 68 Coding exercises ........................................................................................................ 68 Replacement--Root operation R ...................................................................................... 69 Example: Prosthetic lens implantation........................................................................ 69 Coding exercises ........................................................................................................ 70 Supplement--Root operation U ........................................................................................ 71 Example: Posterior colporrhaphy with Gynemesh ..................................................... 71 Coding exercises ........................................................................................................ 72 Change--Root operation 2 ............................................................................................... 72 Coding note: Change.................................................................................................. 72 Example: Percutaneous endoscopic gastrostomy (PEG) tube exchange.................. 73 Coding exercises ........................................................................................................ 73 Removal--Root operation P ............................................................................................. 73 Coding note: Removal ................................................................................................ 73 Example: Removal of right forearm external fixator ................................................... 74 Coding exercises ........................................................................................................ 74 Revision--Root operation W............................................................................................. 74 Coding note: Revision................................................................................................. 75

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Example: Revision of artificial anal sphincter ............................................................. 75 Coding exercises ........................................................................................................ 75 Root operations involving examination only ............................................................................ 76 Inspection--Root operation J............................................................................................ 76 Example: Diagnostic colposcopy with examination of cervix ..................................... 76 Coding exercises ........................................................................................................ 77 Map--Root operation K..................................................................................................... 77 Example: Cardiac mapping ........................................................................................ 77 Coding exercises ........................................................................................................ 78 Root operations that define other repairs ................................................................................ 78 Control--Root operation 3 ................................................................................................ 78 Coding note: Control................................................................................................... 79 Example: Re-opening of laparotomy site with ligation of arterial bleeder .................. 79 Coding exercises ........................................................................................................ 79 Repair--Root operation Q................................................................................................. 79 Example: Left open inguinal herniorrhaphy ................................................................ 80 Coding exercises ........................................................................................................ 80 Root operations that define other objectives ........................................................................... 80 Fusion--Root operation G ................................................................................................ 81 Example: Anterior cervical fusion C-2 through C-4 with bone bank graft................... 81 Coding exercises ........................................................................................................ 82 Alteration--Root operation 0............................................................................................. 82 Coding note: Alteration ............................................................................................... 82 Example: Cosmetic blepharoplasty ............................................................................ 82 Coding exercises ........................................................................................................ 83 Creation--Root operation 4 .............................................................................................. 83 Coding note: Harvesting autograft tissue ................................................................... 84 Exmample: Creating a vagina in a male patient using autograft ................................ 84 Coding exercises ........................................................................................................ 84

Chapter 3: Procedures in the Medical and Surgical-related sections ...... 85

List of Medical and Surgical-related sections of ICD-10-PCS ................................................. 85 Obstetrics--Section 1 ....................................................................................................... 86 Root operations .......................................................................................................... 86 Coding note: Abortion ................................................................................................. 86 Example: Transvaginal abortion using vacuum aspiration technique ........................ 86 Coding note: Delivery ................................................................................................. 87 Example: Manually-assisted delivery ......................................................................... 87 Coding exercises ........................................................................................................ 87 Placement--Section 2....................................................................................................... 88 Root operations .......................................................................................................... 88 Administration--Section 3 ................................................................................................. 91 Root operations .......................................................................................................... 91 Measurement and Monitoring--Section 4......................................................................... 92 Root operations .......................................................................................................... 92 Extracorporeal Assistance and Performance--Section 5 ................................................. 94 Root operations .......................................................................................................... 94 Extracorporeal Therapies--Section 6 ............................................................................... 96 Root operations .......................................................................................................... 96 Osteopathic--Section 7 .................................................................................................... 99 Example: Fascial release of abdomen, osteopathic treatment .................................. 99

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Example: General osteopathic mobilization of legs.................................................... 99 Coding exercises ........................................................................................................ 99 Other Procedures--Section 8 ......................................................................................... 100 Example: Acupuncture.............................................................................................. 100 Example: Yoga therapy ............................................................................................ 100 Coding exercises ...................................................................................................... 100 Chiropractic--Section 9 .................................................................................................. 101 Example: Chiropractic treatment of cervical spine, short lever specific contact....... 101 Example: Non-manual chiropractic manipulation of pelvis....................................... 101 Coding exercises ...................................................................................................... 101

Chapter 4: Procedures in the ancillary sections................................... 103

List of ancillary sections in ICD-10-PCS................................................................................ 103 Imaging--Section B ............................................................................................................... 103

Root types ....................................................................................................................... 104 Example: X-ray of right clavicle, limited study .......................................................... 104 Example: Fluoroscopy of renal dialysis shunt using CO2 contrast .......................... 104 Example: CT of brain without contrast followed by high osmolar contrast ............... 105 Example: MRI of liver using Gadoteridol .................................................................. 105 Example: Ultrasound of prostate gland .................................................................... 105 Coding exercises ...................................................................................................... 105

Nuclear Medicine--Section C................................................................................................ 106 Root types ....................................................................................................................... 106 Example: Adenosine sestamibi (technetium) planar scan of heart muscle at rest... 107 Example: Technetium tomo scan of liver.................................................................. 107 Coding exercises ...................................................................................................... 107

Radiation Therapy--Section D .............................................................................................. 108 Root type ......................................................................................................................... 108 Example: LDR Brachytherapy of cervix using Iridium 192 ....................................... 108 Example: Intraoperative radiation therapy (IORT) of bladder................................... 108 Coding exercises ...................................................................................................... 109

Physical Rehabilitation and Diagnostic Audiology--Section F.............................................. 109 Root types ....................................................................................................................... 109 Coding note: Treatment ............................................................................................ 110 Example: Wound care treatment of left calf ulcer using pulsatile lavage ................. 110 Coding note: Assessment......................................................................................... 110 Example: Articulation and phonology assessment using spectrograph ................... 111 Coding note: Device Fitting ...................................................................................... 111 Example: Individual fitting of moveable brace, right knee ........................................ 111 Coding note: Caregiver Training............................................................................... 111 Example: Caregiver training in feeding, no special equipment used ....................... 112 Coding exercises ...................................................................................................... 112

Mental Health--Section G ..................................................................................................... 113 Root Type ........................................................................................................................ 113 Example: Galvanic skin response (GSR) biofeedback............................................. 113 Coding exercises ...................................................................................................... 114

Substance Abuse Treatment--Section H.............................................................................. 114 Example: Pharmacotherapy treatment with Antabuse for alcohol addiction ............ 115 Coding exercises ...................................................................................................... 115

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Appendix A. ICD-10-PCS definitions ..................................................... 117

Root operations ..................................................................................................................... 117 Approaches ......................................................................................................................... 122

Appendix B. ICD-10-PCS device and substance classification ............... 123

PCS device classification....................................................................................................... 123 Device and procedural objective ..................................................................................... 123 Device and location ......................................................................................................... 124 Device and removability .................................................................................................. 124

Device distribution in PCS ..................................................................................................... 124 PCS substance classification ................................................................................................ 126

Substance and procedural objective ............................................................................... 126 Substance and removability ............................................................................................ 126 Substance distribution in Administration section ................................................................... 126 Classification of substance in ancillary sections.................................................................... 127 Substance distribution in ancillary sections ........................................................................... 127 Equipment and PCS coding................................................................................................... 127 Equipment and procedural objective............................................................................... 128 Equipment and location................................................................................................... 128 Equipment and removability............................................................................................ 128 Summary ......................................................................................................................... 129

Glossary ......................................................................................... 131

Index

......................................................................................... 133

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