ICD-10-PCS Reference Manual - Centers for Medicare & Medicaid ...
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
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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--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 .................................................................................. 40 Coding note: Anastomotic technique.......................................................................... 40 Coding exercises ........................................................................................................ 40
Detachment--Root operation 6......................................................................................... 41 Detachment qualifiers ................................................................................................. 41 Example: Fifth toe ray amputation .............................................................................. 42 Coding note: Qualifier value ....................................................................................... 42 Coding exercises ........................................................................................................ 43
Destruction--Root operation 5.......................................................................................... 43 Example: Radiofrequency coagulation of the trigeminal nerve .................................. 44 Coding note: Approach value ..................................................................................... 44 Coding exercises ........................................................................................................ 44
Extraction--Root 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--Root operation 9 ............................................................................................. 46 Example: Urinary nephrostomy catheter placement .................................................. 47 Coding exercises ........................................................................................................ 47 Extirpation--Root operation C .......................................................................................... 48 Example: De-clotting of AV dialysis graft.................................................................... 48 Coding note: body part value...................................................................................... 48 Coding exercises ........................................................................................................ 49 Fragmentation--Root operation F .................................................................................... 49 ESWL of left kidney .................................................................................................... 49 Coding exercises ........................................................................................................ 50
Root operations involving cutting or separation only ............................................................... 50 Division--Root operation 8 ............................................................................................... 51 Example: Anal sphincterotomy ................................................................................... 51 Coding note: Approach value ..................................................................................... 51 Coding exercises ........................................................................................................ 51 Release--Root operation N .............................................................................................. 52 Example: Release of median nerve............................................................................ 52 Coding note: body part value...................................................................................... 53
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Coding exercises ........................................................................................................ 53 Root operations that put in/put back or move some/all of a body part .................................... 53
Transplantation--Root operation Y................................................................................... 54 Example: Right kidney transplant (syngeneic) ........................................................... 54 Coding note: bone marrow transplant ........................................................................ 55 Coding exercises ........................................................................................................ 55
Reattachment--Root operation M..................................................................................... 55 Example: Complex reattachment, left index finger ..................................................... 56 Coding exercises ........................................................................................................ 56
Transfer--Root operation X .............................................................................................. 57 Example: Fasciocutaneous flap from scalp to cheek ................................................. 57 Coding note: body system value ................................................................................ 57 Coding exercises ........................................................................................................ 58
Reposition--Root 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--Root operation V........................................................................................... 60 Example: Laparoscopic gastroesophageal fundoplication ......................................... 60 Coding exercises ........................................................................................................ 61 Occlusion--Root operation L ............................................................................................ 61 Example: Uterine artery embolization......................................................................... 61 Coding exercises ........................................................................................................ 62 Dilation--Root operation 7 ................................................................................................ 62 Example: PTCA of left anterior descending ............................................................... 63 Coding exercises ........................................................................................................ 63 Bypass--Root operation 1 ................................................................................................ 64 Example: Aorto-bifemoral bypass graft ...................................................................... 64 Coding exercises ........................................................................................................ 64
Root operations that always involve a device ......................................................................... 65 Insertion--Root operation H.............................................................................................. 66 Example: Placement of totally implanted central venous access device ................... 66 Coding note: imaging guidance .................................................................................. 67 Coding exercises ........................................................................................................ 67 Replacement--Root operation R ...................................................................................... 68 Example: Prosthetic lens implantation........................................................................ 68 Coding exercises ........................................................................................................ 69 Supplement--Root operation U ........................................................................................ 69 Example: Posterior colporrhaphy with Gynemesh ..................................................... 70 Coding exercises ........................................................................................................ 70 Change--Root operation 2 ............................................................................................... 71 Coding note: Change.................................................................................................. 71 Example: Percutaneous endoscopic gastrostomy (PEG) tube exchange.................. 71 Coding exercises ........................................................................................................ 71 Removal--Root operation P ............................................................................................. 72 Coding note: Removal ................................................................................................ 72 Example: Removal of right forearm external fixator ................................................... 72 Coding exercises ........................................................................................................ 72 Revision--Root operation W............................................................................................. 73 Coding note: Revision................................................................................................. 73 Example: Revision of artificial anal sphincter ............................................................. 73 Coding exercises ........................................................................................................ 74
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