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ICD-10-PCS Coding in the Medical and Surgical Subsection
 
 

ICD-10-PCS Coding in the Medical and Surgical Subsection

 

All codes from the Medical and Surgical subsection in ICD-10-PCS are seven characters. The letters O and I are not used, so they cannot be confused with the numbers 0 and 1.

ICD-10-PCS Medical and Surgical Subsection: Body System

The second character of a code defines the body system or general anatomical region. This makes it easier for the coder to navigate the system and quickly provides information regarding the procedure. Procedures with the same second character are from the same anatomical region or body system. A procedure code in the general anatomical regions (Value W) should only be used when the procedure is performed on an anatomical region rather than a certain part of the body or when no information supports the assignment of a code to a body part. Example: Control of postoperative hemorrhage is coded to the root operation "Control," which is found in the general anatomical regions Value W. Also, body systems considered "upper" are located above the diaphragm, and those considered "lower" are located below the diaphragm (Barta, DeVault, & Zeisset, 2011).

Medical and Surgical Subsection by Body System Values 1 through 9

Body System

Value

Central Nervous (525)

0

Peripheral Nervous (526)

1

Heart and Great Vessels (527)

2

Upper Arteries (528)

3

Lower Arteries (529)

4

Upper Veins (530)

5

Lower Veins (531)

6

Lymphatic and Hemic (532)

7

Eye (533)

8

Ear, Nose, Sinus (534)

9

Medical and Surgical Subsection by Body System Values B through Y

Body System

Value

Respiratory (535)

B

Mouth and Throat (536)

C

Gastrointestinal (537)

D

Hepatobiliary and Pancreas (538)

F

Endocrine ((539)

G

Skin and Breast (540)

H

Subcutaneous Tissue and Fascia (541)

J

Muscles (542)

K

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Tendons (543)

L

Bursae and Ligaments (544)

M

Head and Facial Bones (545)

N

Upper Bones (546)

P

Lower Bones (547)

Q

Upper Joints (548)

R

Lower Joints (549)

S

Urinary (550)

T

Female Reproductive (551)

U

Male Reproductive (552)

V

Anatomical Regions, General (553)

W

Anatomical Regions, Upper Extremities (554)

X

Anatomical Regions, Lower Extremities (555)

Y

ICD-10-PCS Medical and Surgical Subsection: Root Operations  

The root operation is defined by the third character, which is the objective of the procedure. ICD-10-PCS contains 31 root operations, arranged by groups with similar attributes. Multiple codes are needed when multiple procedures defined by distinct objectives are performed (Barta, DeVault, & Zeisset, 2011).

To determine the appropriate root operation, the coder has to apply the full definition of the root operation from the PCS Tables. Procedure components specified in the root operation definition and explanation are not coded separately. Also, procedural steps for reaching and closing the operative sites are not coded separately. Examples: Resection of a joint during a joint replacement procedure is included in the Replacement root operation definition, so it would not be coded separately. When a laparotomy is performed so the surgeon can reach the operative site during an open liver biopsy, it would not be coded separately (Barta, DeVault, & Zeisset, 2011).

Multiple Procedure Coding

Multiple procedures are coded during the same operative episode only if:

  • The same root operation is also performed on different body parts as defined by distinct values of the body part. Example: Diagnostic excision of gallbladder and pancreas are coded separately.

  • The same root operation is repeated at different body sites, which are included in the same body part value. Example: Excision of the bicep muscle and excision of the triceps muscle are both included in the upper arm muscle body part value.

  • Multiple root operations with distinct objectives are performed on the same body part. Example: Destruction of transverse colon lesion and bypass of transverse colon are coded separately.

  • The intended root operation is attempted with one approach, but is converted with another approach. Example: Laparoscopic appendectomy converted to an open appendectomy is coded as percutaneous endoscopic Inspection and open Resection (Barta, DeVault, & Zeisset, 2011).

Medical and Surgical Subsection Root Operations

Alteration Bypass Change Control Creation Destruction Detachment Dilation Division Drainage  Excision Extirpation Fragmentation Fusion Insertion Inspection Map Occlusion Reattachment Release Removal Repair Replacement Reposition   Resection Restriction Revision Supplement Transfer Transplantation

ICD-10-PCS Medical and Surgical Subsection: Body Part

The fourth character defines the body part or specific anatomical site, which is where the procedure was performed. Approximately 34 possible body part values are included in each body system, and the specific site is different from character 2 (body system) (Barta, DeVault, & Zeisset, 2011).

When a procedure is performed on a body part that does not have a body part value assigned, the coder should assign the body part value the number that corresponds with the whole body part. Example: When a procedure is performed on the alveolar process of the mandible, it is coded to the mandible body part, as no body part code exists for alveolar process. When using the prefix "peri" with a body part, that body part value is defined as that body part which was named. Example: A procedure site is listed as "periumbilical," so it is coded to the abdomen body part (Barta, DeVault, & Zeisset, 2011).

When a body system does not specify a separate body part value for fingers and toes, procedures performed on these structures are coded for the body part value of the hands and feet. Example: Excision of toe muscle is coded to one of the foot muscle body part values in the Muscles body system. Also, when a procedure is done on the skin, subcutaneous tissue, or fascia that overlies a joint, the procedure is coded to the body part that is applicable. Example: Elbow and Wrist are coded to Lower Arm, whereas Shoulder is coded to Upper Arm (Barta, DeVault, & Zeisset, 2011).

ICD-10-PCS Medical and Surgical Subsection: Approaches

The fifth character defines the approach, which is also called the technique. The approach is what is used to reach the surgical site. There are seven approach values in the Medical and Surgical subsection: open, percutaneous, percutaneous endoscopic, via natural or artificial opening, via natural or artificial opening endoscopic, via natural or artificial opening with percutaneous endoscopic assistance. When assigning the approach value, the coder should understand that the approach defines the technique, not the instruments used (Barta, DeVault, & Zeisset, 2011).

Approaches

Value

Approach

Description

Guidelines

Example

0

Open

Cutting through skin, membranes, or body layers

B5.2

Open resection of the cecum

3

Percutaneous

Enter by puncture or minor incision

B5.4

Percutaneous drainage of ascites

4

Percutaneous Endoscopic

Enter by puncture or minor incision and visualize with endoscope

 

Laparoscopic cholecystectomy

7

Via Natural or Artificial Opening

Enter through a natural or artificial opening

 

Digital rectal examination

8

Via Natural or Artificial Opening Endoscopic

Enter through a natural or artificial opening and visualize with endoscope

 

Hysteroscopy

F

Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance

Enter through a natural or artificial opening by puncture or incision by instrumentation and use of visual endoscope

 

Laparoscopic-assisted vaginal hysterectomy

X

External

Procedure performed directly on skin or membrane

B5.3a

B5.3b

Resection of tonsils

 

ICD-10-PCS Medical and Surgical Subsection: Device  

For many procedures, the surgeon leaves a device in place. The sixth character identifies the various devices, and device values are separated into four groups: Grafts and Prostheses, Implants, Simple or Mechanical Appliances, and Electronic Appliances. Only two significant NEC options apply in the Medical and Surgical subsection: the root operation value Q, Repair and the device value Y, Other Device (Barta, DeVault, & Zeisset, 2011).

A device is coded only when it remains after the procedure is done. The coder uses the device value "No Device" when no device remains. Materials that are not coded as devices include sutures, radiological markers, ligatures, and temporary drains. When a procedure is performed only on the device, the coder uses the root operations Change, Irrigation, Removal, and Revision. Also, a separate procedure to put in a drainage device is code with the root operation Drainage with the device value Drainage Device (Barta, DeVault, & Zeisset, 2011).

ICD-10-PCS Medical and Surgical Subsection: Qualifier

The seventh character represents a qualifier for the code, and it gives additional information about a specific attribute of the procedure. There are no specific guidelines for qualifiers, and they may have a narrow application. Examples of qualifiers include the second site for a bypass, diagnostic excision or biopsy, and a type of transplant. When coding qualifiers, coders should understand that most procedures do not have these. The default value that indicates "no qualifier" is Z (Barta, DeVault, & Zeisset, 2011).

 
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