ICD-10-PCS Reference Manual - Centers for Medicare & Medicaid Services
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 ............................................................... xi
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 ......................................................... 13
What is ICD-10-PCS? .............................................................................................................. 13
History of ICD-10-PCS ...................................................................................................... 13
ICD-9-CM Volume 3 compared with ICD-10-PCS ............................................................ 14
ICD-10-PCS code structure ..................................................................................................... 14
Characters ......................................................................................................................... 15
Values ........................................................................................................................... 15
Code structure: Medical and Surgical section................................................................... 15
Character 1: Section ................................................................................................... 16
Character 2: Body system .......................................................................................... 16
Character 3: Root operation ....................................................................................... 16
Character 4: Body part................................................................................................ 17
Character 5: Approach................................................................................................ 17
Character 6: Device .................................................................................................... 17
Character 7: Qualifier.................................................................................................. 18
ICD-10-PCS system organization ..................................................................................... 18
Medical and Surgical section ...................................................................................... 19
Medical and Surgical-related sections ........................................................................ 19
Ancillary sections ........................................................................................................ 20
Tables ......................................................................................................................... 21
Index ........................................................................................................................... 22
Definitions ................................................................................................................... 23
Tabular Order File....................................................................................................... 24
ICD-10-PCS design ................................................................................................................. 24
Multiaxial structure ............................................................................................................ 24
Completeness ................................................................................................................... 25
Coronary bypass example .......................................................................................... 26
Unique definitions ....................................................................................................... 26
Expandability ..................................................................................................................... 26
ICD-10-PCS update: PICVA ....................................................................................... 27
Structural integrity ....................................................................................................... 28
ICD-10-PCS additional characteristics .................................................................................... 28
Standardized terminology ................................................................................................. 28
No eponyms or common procedure names ............................................................... 29
No combination codes ................................................................................................ 29
Standardized level of specificity ........................................................................................ 29
ICD-10-PCS Reference Manual
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Table of Contents
Diagnosis information excluded ........................................................................................ 30
NOS code options restricted ............................................................................................. 30
Limited NEC code options ................................................................................................. 30
ICD-10-PCS applications ......................................................................................................... 31
Optimal search capability .................................................................................................. 31
Consistent characters and values ..................................................................................... 32
Code readability ................................................................................................................ 32
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¡ªRoot operation B .............................................................................................. 38
Coding note: Bone marrow and endometrial biopsies ................................................ 38
Example: Excision of sebaceous cyst (right buttock) ................................................. 38
Coding exercises ........................................................................................................ 39
Resection¡ªRoot operation T ............................................................................................ 39
Coding note: Lymph nodes ......................................................................................... 39
Example: Right hemicolectomy .................................................................................. 40
Coding note: Anastomotic technique .......................................................................... 40
Coding exercises ........................................................................................................ 40
Detachment¡ªRoot operation 6......................................................................................... 41
Detachment qualifiers ................................................................................................. 41
Example: Fifth toe ray amputation .............................................................................. 42
Coding note: Qualifier value ....................................................................................... 42
Coding exercises ........................................................................................................ 43
Destruction¡ªRoot operation 5 .......................................................................................... 43
Example: Radiofrequency coagulation of the trigeminal nerve .................................. 44
Coding note: Approach value ..................................................................................... 44
Coding exercises ........................................................................................................ 44
Extraction¡ªRoot operation D ........................................................................................... 45
Example: Suction dilation & curettage ........................................................................ 45
Coding exercises ........................................................................................................ 45
Root operations that take out solids/fluids/gases from a body part ......................................... 46
Drainage¡ªRoot operation 9 ............................................................................................. 46
Example: Urinary nephrostomy catheter placement .................................................. 47
Coding exercises ........................................................................................................ 47
Extirpation¡ªRoot operation C .......................................................................................... 48
Example: De-clotting of AV dialysis graft.................................................................... 48
Coding note: body part value ...................................................................................... 48
Coding exercises ........................................................................................................ 49
Fragmentation¡ªRoot operation F .................................................................................... 49
ESWL of left kidney .................................................................................................... 49
Coding exercises ........................................................................................................ 50
Root operations involving cutting or separation only ............................................................... 50
Division¡ªRoot operation 8 ............................................................................................... 51
Example: Anal sphincterotomy ................................................................................... 51
Coding note: Approach value ..................................................................................... 51
Coding exercises ........................................................................................................ 51
Release¡ªRoot operation N .............................................................................................. 52
Example: Release of median nerve............................................................................ 52
Coding note: body part value ...................................................................................... 53
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Table of Contents
Coding exercises ........................................................................................................ 53
Root operations that put in/put back or move some/all of a body part .................................... 53
Transplantation¡ªRoot operation Y ................................................................................... 54
Example: Right kidney transplant (syngeneic) ........................................................... 54
Coding note: bone marrow transplant ........................................................................ 55
Coding exercises ........................................................................................................ 55
Reattachment¡ªRoot operation M..................................................................................... 55
Example: Complex reattachment, left index finger ..................................................... 56
Coding exercises ........................................................................................................ 56
Transfer¡ªRoot operation X .............................................................................................. 57
Example: Fasciocutaneous flap from scalp to cheek ................................................. 57
Coding note: body system value ................................................................................ 57
Coding exercises ........................................................................................................ 58
Reposition¡ªRoot operation S........................................................................................... 58
Example: Reposition of undescended right testicle from pelvic region to scrotum .... 58
Coding exercises ........................................................................................................ 59
Root operations that alter the diameter/route of a tubular body part ....................................... 59
Restriction¡ªRoot operation V........................................................................................... 60
Example: Laparoscopic gastroesophageal fundoplication ......................................... 60
Coding exercises ........................................................................................................ 61
Occlusion¡ªRoot operation L ............................................................................................ 61
Example: Uterine artery embolization......................................................................... 61
Coding exercises ........................................................................................................ 62
Dilation¡ªRoot operation 7 ................................................................................................ 62
Example: PTCA of left anterior descending ............................................................... 63
Coding exercises ........................................................................................................ 63
Bypass¡ªRoot operation 1 ................................................................................................ 64
Example: Aorto-bifemoral bypass graft ...................................................................... 64
Coding exercises ........................................................................................................ 64
Root operations that always involve a device ......................................................................... 65
Insertion¡ªRoot operation H.............................................................................................. 66
Example: Placement of totally implanted central venous access device ................... 66
Coding note: imaging guidance .................................................................................. 67
Coding exercises ........................................................................................................ 67
Replacement¡ªRoot operation R ...................................................................................... 68
Example: Prosthetic lens implantation........................................................................ 68
Coding exercises ........................................................................................................ 69
Supplement¡ªRoot operation U ........................................................................................ 69
Example: Posterior colporrhaphy with Gynemesh ..................................................... 70
Coding exercises ........................................................................................................ 70
Change¡ªRoot operation 2 ............................................................................................... 71
Coding note: Change .................................................................................................. 71
Example: Percutaneous endoscopic gastrostomy (PEG) tube exchange.................. 71
Coding exercises ........................................................................................................ 71
Removal¡ªRoot operation P ............................................................................................. 72
Coding note: Removal ................................................................................................ 72
Example: Removal of right forearm external fixator ................................................... 72
Coding exercises ........................................................................................................ 72
Revision¡ªRoot operation W ............................................................................................. 73
Coding note: Revision................................................................................................. 73
Example: Revision of artificial anal sphincter ............................................................. 73
Coding exercises ........................................................................................................ 74
ICD-10-PCS Reference Manual
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