ICD-10-PCS Manual: Understanding Medical & Surgical Procedure Coding, Study notes of Nuclear medicine

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ICD-10-PCS Reference Manual

Table of Contents

ICD-10-PCS Reference Manual

ICD-10-PCS Reference Manual

ICD-10-PCS Reference Manual

ICD-10-PCS Reference Manual

 - Diagnosis information excluded - NOS code options restricted - Limited NEC code options 

• ICD-10-PCS applications
  • Optimal search capability
  • Consistent characters and values
  • Code readability
• Chapter 2: Procedures in the Medical and Surgical section
  • Root operation groups
  • Root operations that take out some or all of a body part.........................................................
    • Excision—Root operation B
      • Coding note: Bone marrow and endometrial biopsies
      • Example: Excision of sebaceous cyst (right buttock)
      • Coding exercises
    • Resection—Root operation T
      • Coding note: Lymph nodes
      • Example: Right hemicolectomy
      • Coding note: Anastomotic technique
      • Coding exercises
    • Detachment—Root operation 6.........................................................................................
      • Detachment qualifiers
      • Example: Fifth toe ray amputation
      • Coding note: Qualifier value
      • Coding exercises
    • Destruction—Root operation
      • Example: Radiofrequency coagulation of the trigeminal nerve
      • Coding note: Approach value
      • Coding exercises
    • Extraction—Root operation D
      • Example: Suction dilation & curettage
      • Coding exercises
  • Root operations that take out solids/fluids/gases from a body part
    • Drainage—Root operation
      • Example: Urinary nephrostomy catheter placement
      • Coding exercises
    • Extirpation—Root operation C
      • Example: De-clotting of AV dialysis graft....................................................................
      • Coding note: body part value
      • Coding exercises
    • Fragmentation—Root operation F
      • ESWL of left kidney
      • Coding exercises
  • Root operations involving cutting or separation only
    • Division—Root operation
      • Example: Anal sphincterotomy
      • Coding note: Approach value
      • Coding exercises
    • Release—Root operation N
      • Example: Release of median nerve............................................................................
      • Coding note: body part value
    • Coding exercises Table of Contents
• Root operations that put in/put back or move some/all of a body part
  • Transplantation—Root operation Y
    • Example: Right kidney transplant (syngeneic)
    • Coding note: bone marrow transplant
    • Coding exercises
  • Reattachment—Root operation M.....................................................................................
    • Example: Complex reattachment, left index finger
    • Coding exercises
  • Transfer—Root operation X
    • Example: Fasciocutaneous flap from scalp to cheek
    • Coding note: body system value
    • Coding exercises
  • Reposition—Root operation S...........................................................................................
    • Example: Reposition of undescended right testicle from pelvic region to scrotum
    • Coding exercises
• Root operations that alter the diameter/route of a tubular body part
  • Restriction—Root operation V...........................................................................................
    • Example: Laparoscopic gastroesophageal fundoplication
    • Coding exercises
  • Occlusion—Root operation L
    • Example: Uterine artery embolization.........................................................................
    • Coding exercises
  • Dilation—Root operation
    • Example: PTCA of left anterior descending
    • Coding exercises
  • Bypass—Root operation
    • Example: Aorto-bifemoral bypass graft
    • Coding exercises
• Root operations that always involve a device
  • Insertion—Root operation H..............................................................................................
    • Example: Placement of totally implanted central venous access device
    • Coding note: imaging guidance
    • Coding exercises
  • Replacement—Root operation R
    • Example: Prosthetic lens implantation........................................................................
    • Coding exercises
  • Supplement—Root operation U
    • Example: Posterior colporrhaphy with Gynemesh
    • Coding exercises
  • Change—Root operation
    • Coding note: Change
    • Example: Percutaneous endoscopic gastrostomy (PEG) tube exchange..................
    • Coding exercises
  • Removal—Root operation P
    • Coding note: Removal
    • Example: Removal of right forearm external fixator
    • Coding exercises
  • Revision—Root operation W
    • Coding note: Revision.................................................................................................
    • Example: Revision of artificial anal sphincter
    • Coding exercises
  • Root operations involving examination only Table of Contents
    • Inspection—Root operation J
      • Example: Diagnostic colposcopy with examination of cervix
      • Coding exercises
    • Map—Root operation K
      • Example: Cardiac mapping
      • Coding exercises
  • Root operations that define other repairs
    • Control—Root operation
      • Coding note: Control
      • Example: Re-opening of laparotomy site with ligation of arterial bleeder
      • Coding exercises
    • Repair—Root operation Q
      • Example: Left open inguinal herniorrhaphy
      • Coding exercises
  • Root operations that define other objectives
    • Fusion—Root operation G
      • Example: Anterior cervical fusion C-2 through C-4 with bone bank graft
      • Coding exercises
    • Alteration—Root operation
      • Coding note: Alteration
      • Example: Cosmetic blepharoplasty
      • Coding exercises
    • Creation—Root operation
      • Coding note: Harvesting autograft tissue
      • Exmample: Creating a vagina in a male patient using autograft
      • Coding exercises
• Chapter 3: Procedures in the Medical and Surgical-related sections
  • List of Medical and Surgical-related sections of ICD-10-PCS
    • Obstetrics—Section
      • Root operations
      • Coding note: Abortion
      • Example: Transvaginal abortion using vacuum aspiration technique
      • Coding note: Delivery
      • Example: Manually-assisted delivery
      • Coding exercises
    • Placement—Section
      • Root operations
    • Administration—Section
      • Root operations
    • Measurement and Monitoring—Section
      • Root operations
    • Extracorporeal Assistance and Performance—Section
      • Root operations
    • Extracorporeal Therapies—Section
      • Root operations
    • Osteopathic—Section
      • Example: Fascial release of abdomen, osteopathic treatment
      • Example: General osteopathic mobilization of legs
      • Coding exercises
    • Other Procedures—Section Table of Contents
      • Example: Acupuncture................................................................................................
      • Example: Yoga therapy
      • Coding exercises
    • Chiropractic—Section
      • Example: Chiropractic treatment of cervical spine, short lever specific contact.........
      • Example: Non-manual chiropractic manipulation of pelvis
      • Coding exercises
• Chapter 4: Procedures in the ancillary sections
  • List of ancillary sections in ICD-10-PCS
  • Imaging—Section B
    • Root types
      • Example: X-ray of right clavicle, limited study
      • Example: Fluoroscopy of renal dialysis shunt using CO2 contrast
      • Example: CT of brain without contrast followed by high osmolar contrast
      • Example: MRI of liver using Gadoteridol
      • Example: Ultrasound of prostate gland
      • Coding exercises
  • Nuclear Medicine—Section C
    • Root types
      • Example: Adenosine sestamibi (technetium) planar scan of heart muscle at rest
      • Example: Technetium tomo scan of liver..................................................................
      • Coding exercises
  • Radiation Therapy—Section D
    • Root type
      • Example: LDR Brachytherapy of cervix using Iridium
      • Example: Intraoperative radiation therapy (IORT) of bladder...................................
      • Coding exercises
  • Physical Rehabilitation and Diagnostic Audiology—Section F
    • Root types
      • Coding note: Treatment
      • Example: Wound care treatment of left calf ulcer using pulsatile lavage
      • Coding note: Assessment
      • Example: Articulation and phonology assessment using spectrograph
      • Coding note: Device Fitting
      • Example: Individual fitting of moveable brace, right knee
      • Coding note: Caregiver Training
      • Example: Caregiver training in feeding, no special equipment used
      • Coding exercises
  • Mental Health—Section G
    • Root Type
      • Example: Galvanic skin response (GSR) biofeedback
      • Coding exercises
  • Substance Abuse Treatment—Section H - Example: Pharmacotherapy treatment with Antabuse for alcohol addiction - Coding exercises
  • New Technology–Section X
    • Example: New Technology
      • Coding note: Seventh Character New Technology Group
    • Body system values
    • Root operations Table of Contents
    • Body part values
    • Device/Substance/Technology values
      • Coding exercises
• Appendix A. ICD- 10 - PCS definitions
  • Root operations
  • Approaches
• Appendix B. ICD- 10 - PCS device and substance classification
  • PCS device classification.......................................................................................................
    • Device and procedural objective
    • Device and location
    • Device and removability
  • Device distribution in PCS
  • PCS substance classification
    • Substance and procedural objective
    • Substance and removability
  • Substance distribution in Administration section
  • Classification of substance in ancillary sections
  • Substance distribution in ancillary sections
  • Equipment and PCS coding...................................................................................................
    • Equipment and procedural objective
    • Equipment and location
    • Equipment and removability
  • Summary
• Glossary
• Index

Preface

The International Classification of Diseases Tenth Revision Procedure Coding System (ICD-10- PCS) is a new system for coding inpatient procedures that was developed for the Centers for Medicare and Medicaid Services (CMS).

This manual is written as a general introduction for data managers, payers, administrators, and medical record coders. For readers who do not need a detailed understanding of ICD-10-PCS but would like a general introduction, the material in chapter 1 and the appendices is recommended.

Manual organization

The manual is organized into the following chapters and appendices. A glossary also provides a list of terms introduced in the manual.

Chapter 1 - Overview

Includes a general introduction to ICD-10-PCS, a brief history of its development, and a presentation of the code structure, organization, and characteristics. The first part of the overview contains basic information; the second and third parts discuss structure, characteristics, and applications in more detail.

Chapter 2 - Procedures in the Medical and Surgical section

Provides reference material for each root operation in the Medical and Surgical section (0), with the full definition, additional explanation as needed, a code example, and coding exercises for each root operation.

Chapter 3 - Procedures in the Medical and Surgical-related sections

Provides reference material for each of the Medical and Surgical-related sections (1 through 9), with definitions, additional explanation as needed, a code example, and coding exercises for each section.

Chapter 4 - Procedures in the ancillary sections

Provides reference material for each of the ancillary sections (B through D, F through H), with definitions, additional explanation as needed, a code example, and coding exercises for each section.

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Chapter 1: ICD-10-PCS overview

The International Classification of Diseases Tenth Revision Procedure Coding System (ICD-10- PCS) was created to accompany the World Health Organization’s (WHO) ICD-10 diagnosis classification. The new procedure coding system was developed to replace ICD-9-CM procedure codes for reporting inpatient procedures.

Unlike the ICD-9-CM classification, ICD-10-PCS was designed to enable each code to have a standard structure and be very descriptive, and yet flexible enough to accommodate future needs. Information about the structure, organization, and application of ICD-10-PCS codes, along with reference material for coding with ICD-10-PCS, is provided in this manual.

This chapter contains the following parts:

• What is ICD-10-PCS?
• ICD-10-PCS code structure
• ICD-10-PCS system organization
• ICD-10-PCS design
• ICD-10-PCS additional characteristics
• ICD-10-PCS applications

More specific information on coding with ICD-10-PCS is found in chapters 2 through 4 of this manual.

What is ICD-10-PCS?

ICD-10-PCS is a procedure coding system that will be used to collect data, determine payment, and support the electronic health record for all inpatient procedures performed in the United States.

History of ICD-10-PCS

The World Health Organization has maintained the International Classification of Diseases (ICD) for recording cause of death since 1893. It has updated the ICD periodically to reflect new discoveries in epidemiology and changes in medical understanding of disease.

The International Classification of Diseases Tenth Revision (ICD-10), published in 1992, is the latest revision of the ICD. The WHO authorized the National Center for Health Statistics (NCHS) to develop a clinical modification of ICD-10 for use in the United States. This version of ICD-10 is called ICD-10-CM. ICD-10-CM is intended to replace the previous U.S. clinical modification, ICD- 9-CM, that has been in use since 1979. ICD-9-CM contains a procedure classification; ICD-10- CM does not.

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ICD-10-PCS overview

The Centers for Medicare and Medicaid Services, the agency responsible for maintaining the inpatient procedure code set in the U.S., contracted with 3M Health Information Systems in 1993 to design and then develop a procedure classification system to replace Volume 3 of ICD-9-CM. ICD-10-PCS is the result.

ICD-10-PCS was initially released in 1998. It has been updated annually since that time.

ICD-9-CM Volume 3 compared with ICD-10-PCS

With ICD-10 implementation, the U.S. clinical modification of the ICD will not include a procedure classification based on the same principles of organization as the diagnosis classification. Instead, a separate procedure coding system has been developed to meet the rigorous and varied demands that are made of coded data in the healthcare industry. This represents a significant step toward building a health information infrastructure that functions optimally in the electronic age.

The following information highlights some of the basic differences between ICD-9-CM Volume 3 and ICD-10-PCS:

ICD-9-CM Volume 3

• Follows ICD structure (designed for diagnosis coding)
• Codes available as a fixed/finite set in list form
• Codes are numeric
• Codes are 3 through 4 digits long

ICD-10-PCS

• Designed/developed to meet healthcare needs for a procedure code system
• Codes constructed from flexible code components (values) using tables
• Codes are alphanumeric
• All codes are seven characters long

ICD-10-PCS code structure

Undergirding ICD-10-PCS is a logical, consistent structure that informs the system as a whole, down to the level of a single code. This means that the process of constructing codes in ICD-10- PCS is also logical and consistent: individual letters and numbers, called "values," are selected in sequence to occupy the seven spaces of the code, called "characters."

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ICD-10-PCS overview

Character 1: Section

The first character in the code determines the broad procedure category, or section, where the code is found. In this example, the section is Medical and Surgical. 0 is the value that represents Medical and Surgical in the first character.

For definitions of characters used in the Medical and Surgical section, please refer to the Glossary.

The sample code looks like this so far:

Character 1 Section Medical and Surgical 0

Character 2: Body system

The second character defines the body system—the general physiological system or anatomical region involved. Examples of body systems include Lower Arteries, Central Nervous System, and Respiratory System. In this example, the body system is Tendons, represented by the value L.

Character 1 Section

Character 2 Body System Medical and Surgical

Tendons

0 L

Character 3: Root operation

The third character defines the root operation, or the objective of the procedure. Some examples of root operations are Bypass, Drainage, and Reattachment. In the sample code below, the root operation is Excision. When used in the third character of the code, the value B represents Excision.

Character 1 Section

Character 2 Body System

Character 3

Medical and Surgical

Tendons Excision

0 L B

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ICD-10-PCS overview

For the complete list of root operations and their definitions, please refer to ICD-10-PCS definitions (page 117 ).

Character 4: Body part

The fourth character defines the body part, or specific anatomical site where the procedure was performed. The body system (second character) provides only a general indication of the procedure site. The body part and body system values together provide a precise description of the procedure site.

Examples of body parts are Kidney, Tonsils, and Thymus. In this example, the body part value is 5, Lower Arm and Wrist, Right. When the second character is L, the value 5 when used in the fourth character of the code represents the right lower arm and wrist tendon.

Character 1 Section

Character 2 Body System

Character 3 Root Operation

Character 4 Body Part

Medical and Surgical

Tendons Excision Lower Arm and Wrist, Right 0 L B 5

Character 5: Approach

The fifth character defines the approach, or the technique used to reach the procedure site. Seven different approach values are used in the Medical and Surgical section to define the approach. Examples of approaches include Open and Percutaneous Endoscopic.

In the sample code below, the approach is Open and is represented by the value 0.

Character 1 Section

Character 2 Body System

Character 3 Root Operation

Character 4 Body Part

Character 5 Approach

Medical and Surgical

Tendons Excision Lower Arm and Wrist, Right

Open

0 L B 5 0

For the complete list of approaches and their definitions, please refer to ICD-10-PCS definitions (page 117 ).

Character 6: Device

Depending on the procedure performed, there may or may not be a device left in place at the end of the procedure. The sixth character defines the device. Device values fall into four basic categories:

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ICD-10-PCS overview

Medical and Surgical section

The first section, Medical and Surgical, contains the great majority of procedures typically reported in an inpatient setting. As shown in the previous section discussing ICD-10-PCS code structure, all procedure codes in the Medical and Surgical section begin with the section value 0.

Character 1 Section

Character 2 Body System

Character 3 Root Operation

Character 4 Body Part

Character 5 Approach

Character 6 Device

Character 7 Qualifier

Medical and Surgical

Tendons Excision Lower Arm and Wrist, Right

Open No Device No Qualifier

0 L B 5 0 Z Z

More complete information on coding procedures in the Medical and Surgical section is found in Procedures in the Medical and Surgical section (page 35 ).

Medical and Surgical-related sections

Sections 1 through 9 of ICD-10-PCS comprise the Medical and Surgical-related sections. These sections include obstetrical procedures, administration of substances, measurement and monitoring of body functions, and extracorporeal therapies, as listed below.

• Section 1: Obstetrics
• Section 2: Placement
• Section 3: Administration
• Section 4: Measurement and Monitoring
• Section 5: Extracorporeal Assistance and Performance
• Section 6: Extracorporeal Therapies
• Section 7: Osteopathic
• Section 8: Other Procedures
• Section 9: Chiropractic

In sections 1 and 2, all seven characters define the same aspects of the procedure as in the Medical and Surgical section.

Codes in sections 3 through 9 are structured for the most part like their counterparts in the Medical and Surgical section, with a few exceptions. For example, in sections 5 and 6, the fifth character is defined as duration instead of approach, as in this code for intra-aortic balloon pump (IABP):

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ICD-10-PCS overview

Character 1 Section

Character 2 Body System

Character 3 Root Operation

Character 4 Body System

Character 5 Duration

Character 6 Function

Character 7 Qualifier

Extracorp. Assist. and Performance

Physiological Systems

Assistance Cardiac Continuous Output Balloon Pump

5 A 0 2 2 1 0

Additional differences include these uses of the sixth character:

• Section 3 defines the sixth character as substance.
• Sections 4 and 5 define the sixth character as function.
• Sections 7 through 9 define the sixth character as method.

More complete information on coding procedures in the Medical and Surgical-related sections is found in Procedures in the Medical and Surgical-related sections (page 83 ).

Ancillary sections

Sections B through D and F through H comprise the ancillary sections of ICD-10-PCS. These six sections include imaging procedures, nuclear medicine, and substance abuse treatment, as listed in the following table.

• Section B: Imaging
• Section C: Nuclear Medicine
• Section D: Radiation Therapy
• Section F: Physical Rehabilitation and Diagnostic Audiology
• Section G: Mental Health
• Section H: Substance Abuse Treatment

The definitions of some characters in the ancillary sections differs from that seen in previous sections. In the Imaging section, the third character is defined as type, and the fifth and sixth characters define contrast and contrast/qualifier respectively, as in the CT scan example below.

Character 1 Section

Character 2 Body System

Character 3 Type

Character 4 Body Part

Character 5 Contrast

Character 6 Qualifier

Character 7 Qualifier Imaging Central Nervous

Computerized Tomography

Brain High Osmolar Unenhanced and Enhanced

None

B 0 2 0 0 0 Z

Additional differences include:

• Section C defines the fifth character as radionuclide.
• Section D defines the fifth character as modality qualifier and the sixth character as isotope.

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