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¡ªRoot operation B .............................................................................................. 40

Coding note: Bone marrow and endometrial biopsies ................................................ 40

Example: Excision of sebaceous cyst (right buttock) ................................................. 40

Coding exercises ........................................................................................................ 41

Resection¡ªRoot operation T ............................................................................................ 41

Coding note: Lymph nodes ......................................................................................... 42

Example: Right hemicolectomy .................................................................................. 42

Coding note: Anastomotic technique .......................................................................... 42

Coding exercises ........................................................................................................ 42

Detachment¡ªRoot operation 6......................................................................................... 43

Detachment qualifiers ................................................................................................. 43

Example: Fifth toe ray amputation .............................................................................. 44

Coding exercises ........................................................................................................ 45

Coding note: Qualifier value ....................................................................................... 45

Destruction¡ªRoot operation 5 .......................................................................................... 45

Example: Radiofrequency coagulation of the trigeminal nerve .................................. 46

Coding note: Approach value ..................................................................................... 46

Coding exercises ........................................................................................................ 46

Extraction¡ªRoot 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¡ªRoot operation 9 ............................................................................................. 49

Example: Urinary nephrostomy catheter placement .................................................. 49

Coding exercises ........................................................................................................ 49

Extirpation¡ªRoot operation C .......................................................................................... 50

Example: De-clotting of AV dialysis graft.................................................................... 50

Coding note: body part value ...................................................................................... 50

Coding exercises ........................................................................................................ 51

Fragmentation¡ªRoot operation F .................................................................................... 51

ESWL of left kidney .................................................................................................... 52

Coding exercises ........................................................................................................ 52

Root operations involving cutting or separation only ............................................................... 52

Division¡ªRoot operation 8 ............................................................................................... 53

Example: Anal sphincterotomy ................................................................................... 53

Coding note: Approach value ..................................................................................... 53

Coding exercises ........................................................................................................ 54

Release¡ªRoot 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¡ªRoot operation Y ................................................................................... 56

Example: Right kidney transplant (syngeneic) ........................................................... 57

Coding note: bone marrow transplant ........................................................................ 57

Coding exercises ........................................................................................................ 57

Reattachment¡ªRoot operation M..................................................................................... 58

Example: Complex reattachment, left index finger ..................................................... 58

Coding exercises ........................................................................................................ 58

Transfer¡ªRoot operation X .............................................................................................. 59

Example: Fasciocutaneous flap from scalp to cheek ................................................. 59

Coding note: body system value ................................................................................ 59

Coding exercises ........................................................................................................ 60

Reposition¡ªRoot 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¡ªRoot operation V........................................................................................... 62

Example: Laparoscopic gastroesophageal fundoplication ......................................... 62

Coding exercises ........................................................................................................ 63

Occlusion¡ªRoot operation L ............................................................................................ 63

Example: Uterine artery embolization......................................................................... 63

Coding exercises ........................................................................................................ 64

Dilation¡ªRoot operation 7 ................................................................................................ 64

Example: PTCA of left anterior descending ............................................................... 65

Coding exercises ........................................................................................................ 65

Bypass¡ªRoot operation 1 ................................................................................................ 65

Example: Aorto-bifemoral bypass graft ...................................................................... 66

Coding exercises ........................................................................................................ 66

Root operations that always involve a device ......................................................................... 67

Insertion¡ªRoot operation H.............................................................................................. 68

Example: Port-a-cath placement ................................................................................ 68

Coding note: imaging guidance .................................................................................. 68

Coding exercises ........................................................................................................ 68

Replacement¡ªRoot operation R ...................................................................................... 69

Example: Prosthetic lens implantation........................................................................ 69

Coding exercises ........................................................................................................ 70

Supplement¡ªRoot operation U ........................................................................................ 71

Example: Posterior colporrhaphy with Gynemesh ..................................................... 71

Coding exercises ........................................................................................................ 72

Change¡ªRoot operation 2 ............................................................................................... 72

Coding note: Change .................................................................................................. 72

Example: Percutaneous endoscopic gastrostomy (PEG) tube exchange.................. 73

Coding exercises ........................................................................................................ 73

Removal¡ªRoot operation P ............................................................................................. 73

Coding note: Removal ................................................................................................ 73

Example: Removal of right forearm external fixator ................................................... 74

Coding exercises ........................................................................................................ 74

Revision¡ªRoot operation W ............................................................................................. 74

Coding note: Revision................................................................................................. 75

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