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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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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