ICD-10-PCS Reference Manual

ICD-10-PCS Reference Manual

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....................................................................................................................xii

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 .................................................................................................... 19 Character 7: Qualifier.................................................................................................. 20 ICD-10-PCS system organization ..................................................................................... 20 Medical and Surgical section ...................................................................................... 21 Medical and Surgical-related sections........................................................................ 21 Ancillary sections ........................................................................................................ 22 Tables ......................................................................................................................... 22 Index ........................................................................................................................... 24 List of Codes ............................................................................................................... 25

ICD-10-PCS design ................................................................................................................. 25 Multiaxial structure ............................................................................................................ 25 Completeness ................................................................................................................... 26 Coronary bypass example .......................................................................................... 27 Unique definitions ....................................................................................................... 27 Expandability ..................................................................................................................... 28 ICD-10-PCS update: PICVA ....................................................................................... 28 Structural integrity....................................................................................................... 29

ICD-10-PCS additional characteristics .................................................................................... 29 Standardized terminology ................................................................................................. 29 No eponyms or common procedure names ............................................................... 30

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No combination codes ................................................................................................ 30 Standardized level of specificity ........................................................................................ 30 Diagnosis information excluded ........................................................................................ 31 NOS code options restricted ............................................................................................. 31 Limited NEC code options................................................................................................. 32 ICD-10-PCS applications......................................................................................................... 32 Optimal search capability .................................................................................................. 32 Consistent characters and values ..................................................................................... 33 Code readability ................................................................................................................ 34

Chapter 2: Procedures in the Medical and Surgical section ................... 35

Root operation groups ............................................................................................................. 35 Root operations that take out some or all of a body part......................................................... 37

Excision--Root operation B .............................................................................................. 38 Coding note: Bone marrow and endometrial biopsies................................................ 38 Example: Excision of sebaceous cyst (right buttock) ................................................. 38 Coding exercises ........................................................................................................ 39

Resection--Root operation T............................................................................................ 39 Coding note: Lymph nodes......................................................................................... 39 Example: Right hemicolectomy .................................................................................. 39 Coding note: Anastomotic technique.......................................................................... 40 Coding exercises ........................................................................................................ 40

Detachment--Root operation 6......................................................................................... 40 Detachment qualifiers ................................................................................................. 41 Example: Fifth toe ray amputation .............................................................................. 42 Coding exercises ........................................................................................................ 42 Coding note: Qualifier value ....................................................................................... 43

Destruction--Root operation 5.......................................................................................... 43 Example: Radiofrequency coagulation of the trigeminal nerve .................................. 43 Coding note: Approach value ..................................................................................... 44 Coding exercises ........................................................................................................ 44

Extraction--Root operation D ........................................................................................... 44 Example: Suction dilation & curettage........................................................................ 45

Root operations that take out solids/fluids/gases from a body part......................................... 45 Drainage--Root operation 9 ............................................................................................. 46 Example: Urinary nephrostomy catheter placement .................................................. 46 Coding exercises ........................................................................................................ 46 Extirpation--Root operation C .......................................................................................... 47 Example: De-clotting of AV dialysis graft.................................................................... 47 Coding note: body part value...................................................................................... 48 Coding exercises ........................................................................................................ 48 Fragmentation--Root operation F .................................................................................... 48 ESWL of left kidney .................................................................................................... 48 Coding exercises ........................................................................................................ 49

Root operations involving cutting or separation only ............................................................... 49 Division--Root operation 8 ............................................................................................... 50 Example: Anal sphincterotomy ................................................................................... 50 Coding note: Approach value ..................................................................................... 50 Coding exercises ........................................................................................................ 50 Release--Root operation N .............................................................................................. 51 Example: Release of median nerve............................................................................ 51

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Coding note: body part value...................................................................................... 52 Coding exercises ........................................................................................................ 52 Root operations that put in/put back or move some/all of a body part .................................... 52 Transplantation--Root operation Y................................................................................... 53 Example: Right kidney transplant (syngeneic) ........................................................... 53 Coding note: bone marrow transplant ........................................................................ 54 Coding exercises ........................................................................................................ 54 Reattachment--Root operation M..................................................................................... 54 Example: Complex reattachment, left index finger ..................................................... 54 Coding exercises ........................................................................................................ 55 Transfer--Root operation X .............................................................................................. 55 Example: Fasciocutaneous flap from scalp to cheek ................................................. 56 Coding note: body system value ................................................................................ 56 Coding exercises ........................................................................................................ 56 Reposition--Root operation S........................................................................................... 57 Example: Reposition of undescended right testicle from pelvic region to scrotum .... 57 Coding exercises ........................................................................................................ 57 Root operations that alter the diameter/route of a tubular body part....................................... 58 Restriction--Root operation V........................................................................................... 58 Example: Laparoscopic gastroesophageal fundoplication ......................................... 59 Coding exercises ........................................................................................................ 59 Occlusion--Root operation L ............................................................................................ 60 Example: Uterine artery embolization......................................................................... 60 Coding exercises ........................................................................................................ 60 Dilation--Root operation 7 ................................................................................................ 61 Example: PTCA of left anterior descending ............................................................... 61 Coding exercises ........................................................................................................ 62 Bypass--Root operation 1 ................................................................................................ 62 Example: Aorto-bifemoral bypass graft ...................................................................... 62 Coding exercises ........................................................................................................ 63 Root operations that always involve a device ......................................................................... 63 Insertion--Root operation H.............................................................................................. 64 Example: Port-a-cath placement ................................................................................ 64 Coding note: imaging guidance .................................................................................. 65 Coding exercises ........................................................................................................ 65 Replacement--Root operation R ...................................................................................... 66 Example: Prosthetic lens implantation........................................................................ 66 Coding exercises ........................................................................................................ 67 Supplement--Root operation U ........................................................................................ 67 Example: Posterior colporrhaphy with Gynemesh ..................................................... 68 Coding exercises ........................................................................................................ 68 Change--Root operation 2 ............................................................................................... 69 Coding note: Change.................................................................................................. 69 Example: Percutaneous endoscopic gastrostomy (PEG) tube exchange.................. 69 Coding exercises ........................................................................................................ 69 Removal--Root operation P ............................................................................................. 70 Coding note: Removal ................................................................................................ 70 Example: Removal of right forearm external fixator ................................................... 70 Coding exercises ........................................................................................................ 71 Revision--Root operation W............................................................................................. 71 Coding note: Revision................................................................................................. 71 Example: Revision of artificial anal sphincter ............................................................. 71

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