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ICD-10-Procedure

Coding System(ICD-10-PCS)

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Development Background

CMS awarded a contract to 3M HealthInformation Systems to develop a new

procedure coding system The new system is intended to replace

ICD-9-CM Volume 3 for reporting

inpatient procedures

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Development History

1995 - 1996: First draft of ICD-10-PCS completed

1996 - 1997: Training program developed

Informal testing conductedICD-10-PCS revised

1997 - 1998: Independent formal testing conducted

ICD-10-PCS revisedFinal draft completed

1998-present ICD-10-PCS updated annually

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Major Development Goals

Improve accuracy and efficiency of coding

Reduce training effort

Improve communication with physicians

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Essential Attributes

Completeness

All substantially different procedures have a

unique code

Expandability

The structure of the system allows

incorporation of new procedures as unique

codes

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Standardized terminology

Includes definitions of the terminology used.

While the meaning of specific words can vary in

common usage, ICD-10-PCS defines a single

meaning for each term used in the system.

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Multiaxial

The system has a multi-axial structure.Each character has the same meaning

within a section and across sections to the

extent possible

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General Principles

Diagnostic information is not included inthe code description

A not elsewhere classified option isallowed for new devices and substances

All substantially different procedures aredefined

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General Principles

Limited NOS Option

A general body part, approach, or root

operation can be used when the level of

specificity required is not available in the

record or cannot otherwise be obtained

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General Principles

Limited NOS Option

Body Part:

Example: Liver is used when the specific liver lobe isnot identified

Approach: Open, Percutaneous and Via Natural or Artificial

Openingare used when a more specific type ofapproach is not documented and cannot otherwise bedetermined

Root Operation:

Repair is used when the procedure documentationdoes not support a specific root operation and theinformation cannot otherwise be obtained

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Code Structure Codes are comprised of seven components.

Each component is called a character

All codes are seven characters long

Individual units for each character arerepresented by a letter or number

Each unit is called a value

34 possible values for each character

Digits 0- 9

Letters A-H, J-N, P-Z

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ICD-10-PCS Tables

Each table contains four columns and

varying numbers of rows

Column: Specifies the allowable values for

characters 4-7

Row: Specifies the valid combinations of

values

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Example: Table 0DB Excerpt


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ICD-10-PCS Index

Provides the first three or four values of

the code

The tables must always be used to obtain

the complete code

No eponyms are included


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Index Conventions

Main index term is a root operation, root

procedure type, or common procedure name

Examples: Resection (root operation)Fluoroscopy (root type)

Prostatectomy (common procedure name)

Secondary entries are underneath the main term

PCS Table or code reference as specific as possible


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Index Entry by Body Part

BypassAorta, Thoracic 021W

Aorta, Abdominal 0410Artery, Axillary, Left 03160

Artery, Axillary, Right 03150

Artery, Brachial, Left 03180

Artery, Brachial, Right 03170Artery, Common Carotid, Left 031J0

Artery, Common Carotid, Right 031H0


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Medical and Surgical Section

Character Specification

1stCharacter = Section

2ndCharacter = Body System

3rdCharacter = Root Operation

4thCharacter = Body Part

5thCharacter = Approach

6thCharacter = Device

7thCharacter = Qualifier


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Medical and Surgical Section Principles

The root operation is based on the

objective of the procedure

If multiple procedures as defined by distinct

objectives are performed, then multiple

codes are assigned


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Principles

Root Operation

Value is consistent throughout the section Approach

Value is consistent throughout the section

Body partValue is consistent within a specific body

system


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Section CharacterMedical and Surgical Section


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Section

(Character 1)

Defines the general type of procedure

In the Medical and Surgical Section the firstcharacter is always the number 0


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Body System CharacterMedical and Surgical Section


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Body System

(Character 2)

Defines the general physiological system on which theprocedure is performed, or anatomical region where theprocedure is performed

Uses generally accepted anatomical or physiologicalcategories

Some traditional categories are subdivided into severalbody systems.

Cardiovascular is subdivided into five body systems:Heart and Great Vessels Upper Veins

Upper Arteries Lower Veins

Lower Arteries


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Body Systems

Central Nervous

Peripheral Nervous

Heart and Great Vessels

Upper Arteries

Lower Arteries

Upper VeinsLower Veins

Lymphatic and Hemic

Eye

Ear, Nose, Sinus

Respiratory

Mouth and Throat

Gastrointestinal

Hepatobiliary and Pancreas

Endocrine

Skin and Breast

Subcutaneous Tissue and Fascia

Muscles

Tendons

Bursae and Ligaments

Head and Facial Bones

Upper Bones

Lower Bones

Upper Joints

Lower Joints

Urinary

Female Reproductive

Male ReproductiveAnatomical Regions, General

Anatomical Regions, Upper Extremities

Anatomical Regions, Lower Extremities


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Root Operation

CharacterMedical and Surgical Section


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Root Operation(Character 3)

Defines the objective of the procedure 31 different root operation values

Each root operation identifies a precise

and distinct objective


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Root Operations

AlterationBypassChange

ControlCreationDestructionDetachmentDilation

DivisionDrainage

ReleaseRemovalRepair

ReplacementRepositionResectionRestrictionRevision

SupplementTransferTransplantation


29

Excision

Extirpation

Extraction

Fragmentation

Fusion

Insertion

Inspection

MapOcclusion

Reattachment

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Root Operation Principles

The root operation is coded according to

the objective of the procedure actually

performedDiscontinued or modified procedures coded to

procedure actually performed

Composite terms (e.g., colonoscopy,sigmoidectomy) are not root operations


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Root Operation Principles Combination procedures are coded

separately

Each procedure with a distinct objective duringan operative episode is coded separately

The complete or partial redo of a procedureis coded to the root operation performed

rather than RevisionRevision is confined to correcting a

malfunctioning or displaced device


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Root Operation Groups Procedures that take out or eliminate all or a

portion of a body part

Procedures that involve putting in or on, puttingback, or moving body parts

Procedures that take out or eliminate solid

matter, fluids, or gases from a body part

Procedures that only involve examination of bodyparts and regions


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Root Operation Groups Procedures that can be performed only on tubular

body parts

Procedures that always involve devices

Procedures involving cutting or separation only

Procedures involving other repairs Procedures with other objectives


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Root Operations

Procedures that take out or eliminate

all or a portion of a body part

Excision

Resection

Extraction

DestructionDetachment


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Root Operations

Excision

Definition Cutting out or off, without

replacement, a portion of a body part

Explanation The qualifier Diagnosticis used to

identify excision procedures that are

biopsies

Examples Partial nephrectomy

Liver biopsy


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Root Operations

Resection

Definition Cutting out or off, without replacement,

all of a body part

Examples Total nephrectomy

Total lobectomy of lung


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Root OperationsExtraction

Definition Pulling or stripping out or off all or a portion of

a body part by the use of force

Explanation The qualifier Diagnosticis used to identifyextraction procedures that are biopsies

Examples Dilation and curettage

Vein stripping


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Root Operations

Destruction

Definition Physical eradication of all or a portion of a

body part by the direct use of energy, force ora destructive agent

Explanation None of the body part is physically taken out

Examples Fulguration of rectal polyp

Cautery of skin lesion


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Root Operations

DetachmentDefinition Cutting off all or part of the upper

or lower extremities

Explanation The body part value is the site ofthe detachment, with a qualifier ifapplicable to further specify thelevel where the extremity was

detachedExamples Below knee amputation

Disarticulation of shoulder


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Medical and Surgical SectionRoot Operations

Procedures that involve putting in or on, puttingback, or moving living body parts

Transplantation

Reattachment

Reposition

Transfer


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Root Operations

Transplantation

Definition Putting in or on all or a portion of a living bodypart taken from another individual or animal to

physically take the place and/or function of all ora portion of a similar body part

Explanation The native body part may or may not be taken out,and the transplanted body part may take over all

or a portion of its function

Examples Kidney transplantHeart transplant


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Root Operations

Reattachment

Definition Putting back in or on all or a portion of a

separated body part to its normal location orother suitable location

Explanation Vascular circulation and nervous pathwaysmay or may not be reestablished

Examples Reattachment of handReattachment of avulsed kidney


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Root OperationsRepositionDefinition Moving to its normal location or other suitable

location all or a portion of a body part

Explanation The body part is moved to a new location froman abnormal location, or from a normal locationwhere it is not functioning correctly. The bodypart may or may not be cut out or off to be

moved to the new locationExamples Reposition of undescended testicle

Fracture reduction


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Root OperationsTransfer

Definition Moving, without taking out, all or a portion of

a body part to another location to take over

the function of all or a portion of a body part

Explanation The body part transferred remains connected to

its vascular and nervous supply

Examples Tendon transfer

Skin pedicle flap transfer

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Root Operations

Procedures that take out or eliminate

solid matter, fluids or gases from a body part

Drainage Extirpation

Fragmentation

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Root Operations

Drainage

Definition Taking or letting out fluids and/orgases from a body part

Explanation The qualifier Diagnosticis used toidentify drainage procedures that arebiopsies

Examples ThoracentesisIncision and drainage

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Root Operations

Extirpation

Definition Taking or cutting out solid matter from a bodypart

Explanation The solid matter may be an abnormal byproductof a biological function or a foreign body; it maybe imbedded in a body part or in the lumen of atubular body part. The solid matter may or maynot have been previously broken into pieces

Examples ThrombectomyCholedocholithotomy

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Root Operations

Fragmentation

Definition Breaking solid matter in a body part into pieces

Explanation Physical force (e.g., manual, ultrasonic) applied

directly or indirectly is used to break the solidmatter into pieces. The solid matter may be anabnormal byproduct of a biological function ora foreign body. The pieces of solid matter arenot taken out

Examples Extracorporeal shockwave lithotripsyTransurethral lithotripsy

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Root Operations

Procedures that only involve examination

of body parts and regions

Inspection

Map

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Root Operations

Inspection

Definition Visually and/or manually exploring abody part

Explanation Visual exploration may be performedwith or without optical instrumentation.Manual exploration may be performeddirectly or through intervening body

layers

Examples Diagnostic arthroscopyExploratory laparotomy

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Root Operations

MapDefinition Locating the route of passage of

electrical impulses and/or locatingfunctional areas in a body part

Explanation Applicable only to the cardiacconduction mechanism and the central

nervous system

Examples Cardiac mappingCortical mapping

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Root Operations

Bypass

Definition Altering the route of passage of the contents of a tubular

body part

Explanation Rerouting contents of a body part to a downstream area ofthe normal route, to a similar route and body part, or to an

abnormal route and dissimilar body part. Includes one or

more anastomoses, with or without the use of a device

Examples Coronary artery bypass

Colostomy formation

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Root Operations

Dilation

Definition Expanding an orifice or the lumen of a tubularbody part

Explanation The orifice can be a natural orifice or anartificially created orifice. Accomplished bystretching a tubular body part using intraluminalpressure or by cutting part of the orifice or wallof the tubular body part

Examples Percutaneous transluminal angioplastyPyloromyotomy

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Root Operations

Occlusion

Definition Completely closing the orifice or lumen of atubular body part

Explanation The orifice can be a natural orifice or anartificially created orifice

Example Fallopian tube ligation

Ligation of inferior vena cava

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Root Operations

Restriction

Definition Partially closing the orifice or lumen of a

tubular body partExplanation The orifice can be a natural orifice or an

artificially created orifice

Examples Esophagogastric fundoplication

Cervical cerclage

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Root OperationsProcedures that always involve devices

Insertion

Replacement

Supplement

Removal

Change

Revision

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Root Operations

Insertion

Definition Putting in a nonbiological appliance thatmonitors, assists, performs or prevents aphysiological function but does notphysically take the place of a body part

Examples Insertion of radioactive implantInsertion of central venous catheter

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Root Operations

ReplacementDefinition Putting in or on biological or synthetic material that

physically takes the place and/or function of all or a portionof a body part

Explanation The body part may have been taken out or replaced, or maybe taken out, physically eradicated, or renderednonfunctional during the Replacement procedure. ARemoval procedure is coded for taking out the device usedin a previous replacement procedure

Examples Total hip replacement, bone graftFree skin graft

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Root Operations

SupplementDefinition Putting in or on biological or synthetic material that

physically reinforces or augments the function of a body part

Explanation The biological material is non-living, or the biologicalmaterial is living and from the same individual. The bodypart may have been previously replaced. If the body parthas been previously replaced, the Supplementprocedure isperformed to physically reinforce and/or augment thefunction of the replaced body part

Examples Herniorrhaphy using mesh, free nerve mitral valve ringannuloplasty, put a new acetabular liner in a previous hip

replacement

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Root Operations

Removal

Definition Taking out or off a device from a body part

Explanation If a device is taken out and a similar device put inwithout cutting or puncturing the skin or mucousmembrane, the procedure is coded to the rootoperation Change. Otherwise, the procedure fortaking out a device is coded to the root operation

Removal

Examples Drainage tube removalCardiac pacemaker removal

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Root OperationsChangeDefinition Taking out or off a device from a body

part and putting back an identical or

similar device in or on the same bodypart without cutting or puncturing theskin or a mucous membrane

Explanation All Change procedures are coded using the

approach External

Examples Urinary catheter changeGastrostomy tube change

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Root Operation

Revision

Definition Correcting, to the extent possible, a

malfunctioning or displaced device

Explanation Revision can include correcting a

malfunctioning or displaced device by

taking out or putting in components of the

device such as a screw

Examples Adjustment of position of pacemaker lead

Recementing of hip prosthesis

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Root OperationsProcedures involving cutting or separation

only

Division

Release

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Root OperationsDivision

Definition Cutting into a body part without draining

fluids and/or gasses from the body part inorder to separate or transect a body part

Explanation All or a portion of the body part is

separated into two or more portions

Examples Spinal cordotomy, osteotomy

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Root Operations

Release

Definition Freeing a body part from an abnormalphysical constraint by cutting or by use offorce

Explanation Some of the restraining tissue may be takenout but none of the body part is taken out

Examples AdhesiolysisCarpal tunnel release

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Root Operations

Procedures involving other repairs

Control

Repair

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Root OperationsControl

Definition Stopping, or attempting to stop,post-procedure bleeding

Explanation The site of the bleeding is coded as ananatomical region and not to a specificbody part

Examples Control of post-prostatectomy

hemorrhageControl of post-tonsillectomy hemorrhage

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Root Operations

Repair

Definition Restoring, to the extent possible, a bodypart to its normal anatomic structure andfunction

Explanation Used only when the method toaccomplish the repair is not one of theother root operations

Examples Colostomy takedownSuture of laceration

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Root Operations

Alteration

Definition Modifying the anatomical

structure of a body part withoutaffecting the function of the body part

Explanation Principal purpose is to improveappearance

Examples Face liftBreast augmentation

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Root Operations

Creation

Definition Making a new genital structure that

does not take over the function of a

body part

Explanation Used only for sex change operations

Examples Creation of vagina in a male

Creation of penis in a female

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Root OperationsFusion

Definition Joining together portions of an articular

body part rendering the articular bodypart immobile

Explanation The body part is joined together byfixation device, bone graft, or other

means

Examples Spinal fusionAnkle arthrodesis

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Body Part Character


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Body Part Character(Character 4)

Defines the specific anatomical site where theprocedure is performed

34 possible body part values in each body system

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Body Part Values

Hepatobiliary and Pancreas

Liver

Liver, Right Lobe

Liver, Left Lobe

Gallbladder

Hepatic Duct, Right

Hepatic Duct, Left

Cystic Duct

Common Bile Duct

Ampulla of Vater

Pancreatic Duct

Pancreatic Duct, Accessory

Pancreas

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Approach Character


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Approach(Character 5)

Defines the technique used to reach the site ofthe procedure

7 different approach values

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Approach

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Approaches through the skin or mucous

membrane

Open Percutaneous

Percutaneous Endoscopic

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Approach Definitions

OPEN

Cutting through the skin or mucous

membrane and any other body layersnecessary to expose the site of the

procedure

Example: Abdominal hysterectomy

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Approach DefinitionsPERCUTANEOUS

Entry, by puncture or minor incision, of

instrumentation through the skin or mucousmembrane and any other body layers necessary

to reach the site of the procedure

Example: Needle biopsy of liver

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Approach DefinitionsPERCUTANEOUS ENDOSCOPIC

Entry, by puncture or minor incision, ofinstrumentation through the skin or mucousmembrane and any other body layers necessaryto reach and visualize the site of the procedure

Example: Arthroscopy

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Approach

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Approaches through an orifice

Via Natural or Artificial Opening


Endoscopic

Via Natural or Artificial Opening with

Percutaneous Endoscopic Assistance

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Approach DefinitionsVIA NATURAL OR ARTIFICIAL OPENING

Entry of instrumentation through a natural or

artificial external opening to reach the site of theprocedure

Example: Endotracheal intubation

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VIA NATURAL OR ARTIFICIAL OPENINGENDOSCOPIC

Entry of instrumentation through a natural or

artificial external opening to reach and visualizethe site of the procedure

Example: Sigmoidoscopy

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VIA NATURAL OR ARTIFICIAL OPENINGWITH

PERCUTANEOUS ENDOSCOPIC ASSISTANCE

Entry of instrumentation through a natural orartificial external opening and entry, by puncture orminor incision, of instrumentation through the skinor mucous membrane and any other body layersnecessary to aid in the performance of theprocedure

Example: Laparoscopic-assisted vaginal hysterectomy

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Approach DefinitionsEXTERNAL

Procedures performed directly on the skin or

mucous membrane and procedures performedindirectly by the application of external forcethrough the skin or mucous membrane

Example: Closed fracture reduction

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Device CharacterMedical and Surgical Section

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Device Categories

Therapeutic material that is not absorbed by,eliminated by, or incorporated into a body part (e.g.,radioactive implant, orthopedic pins). Therapeutic

materials that are considered devices can beremoved

Mechanical or electronic appliances used to assist,

monitor, take the place of, or prevent a physiologicalfunction (e.g., diaphragmatic pacemaker, hearingdevice)

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Qualifier


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Qualifier(Character 7)

Defines an additional attribute of the procedure

performed, if applicable

May have a narrow application, to a specific root

operation, body system, or body part

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Examples of Qualifiers

Type of transplant Second site for a bypass

Diagnostic excision (biopsy)

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Obstetrics Section

RLM.MD 06/11

ICD-10-PCS96

Obstetrics Section

8/12/2019 ICD-10-PCS 2013

97/215





4thCharacter = Body Part 5thCharacter = Approach


7th

Character = Qualifier

RLM.MD 06/11

ICD-10-PCS97

8/12/2019 ICD-10-PCS 2013

98/215

Obstetrics Section

Includes only procedures performed on theproducts of conception

Operations on the pregnant female are codedin the Medical and Surgical section (e.g.,episiotomy)

Two root operations unique to this section

Other root operations same as Medical andSurgical section (e.g., Drainage, Inspection)

RLM.MD 06/11

ICD-10-PCS98

Obstetrics Section

8/12/2019 ICD-10-PCS 2013

99/215

Obstetrics Section

Body System(Character 2)

Contains a single body system:

Pregnancy

RLM.MD 06/11

ICD-10-PCS99

Obstetrics Section

8/12/2019 ICD-10-PCS 2013

100/215

Obstetrics Section


Abortion: Artificially terminating a pregnancy

Delivery: Assisting the passage of the products of

conception from the genital canal

RLM.MD 06/11

ICD-10-PCS100

8/12/2019 ICD-10-PCS 2013

101/215

Obstetrics Section

8/12/2019 ICD-10-PCS 2013

102/215

Obstetrics Section

Body Part

Products of conception refers to all components

of a pregnancy, including the fetus, embryo,

amnion, umbilical cord and placenta

There is no differentiation of the products of

conception based on gestational age

RLM.MD 06/11

ICD-10-PCS102

Obstetrics Section

8/12/2019 ICD-10-PCS 2013

103/215

Obstetrics Section

Device(Character 6)

Some device values unique to this section

Examples:Laminaria

Abortifacient

Monitoring Electrode

RLM.MD 06/11

ICD-10-PCS

103

Obstetrics Section

8/12/2019 ICD-10-PCS 2013

104/215

Obstetrics Section

Qualifier(Character 7)

Values are dependent on the rootoperation, approach, or body part

Examples (root operation dependent):

Method of extraction (e.g., low forceps,vacuum)

Substance drained (e.g., amniotic fluid, fetalblood)

RLM.MD 06/11

ICD-10-PCS

104

Obstetrics Section Table 10D

8/12/2019 ICD-10-PCS 2013

105/215

Obstetrics Section Table 10D

RLM.MD 06/11

ICD-10-PCS

105

8/12/2019 ICD-10-PCS 2013

106/215

Placement Section

RLM.MD 06/11

ICD-10-PCS

106

PlacementSection

8/12/2019 ICD-10-PCS 2013

107/215





4thCharacter = Body Region/ Orifice 5thCharacter = Approach


7th


RLM.MD 06/11

ICD-10-PCS

107

Placement Section

8/12/2019 ICD-10-PCS 2013

108/215

Placement Section


Contains two body system values:

Anatomical Regions

Anatomical Orifices

RLM.MD 06/11

ICD-10-PCS

108

Placement Section

8/12/2019 ICD-10-PCS 2013

109/215

Root Operation

(Character 3) Five root operations unique to this section

Compression

Dressing Immobilization

Packing

Traction

Two root operations common to other sectionsChange

Removal

RLM.MD 06/11

ICD-10-PCS

109

Placement Section

8/12/2019 ICD-10-PCS 2013

110/215

Root Operation

(Character 3)Compression: Putting pressure on a body region

Dressing: Putting material on a body region for

protectionImmobilization: Limiting or preventing motion of

a body region

Packing: Putting material in a body region or

orificeTraction: Exerting a pulling force on a body

region in a distal direction

RLM.MD 06/11

ICD-10-PCS

110

Placement Section

8/12/2019 ICD-10-PCS 2013

111/215

Body Regions/Orifices

(Character 4)

Two types of values:

External body regions (e.g., chest wall)

Natural orifices (e.g., mouth and pharynx)

RLM.MD 06/11

ICD-10-PCS

111

Placement Section

8/12/2019 ICD-10-PCS 2013

112/215

Placement Section

Device(Character 6)

Specifies the material or device in the placementprocedure (e.g., splint, bandage)

Includes casts for fractures and dislocations

Devices in the placement section are off the shelf and donot require any extensive design, fabrication or fitting

The placement of devices that require extensive design,fabrication or fitting are coded in the Rehabilitationsection

RLM.MD 06/11

ICD-10-PCS

112

8/12/2019 ICD-10-PCS 2013

113/215

8/12/2019 ICD-10-PCS 2013

114/215

Administration

Section

RLM.MD 06/11

ICD-10-PCS

114

8/12/2019 ICD-10-PCS 2013

115/215

Administration Section

8/12/2019 ICD-10-PCS 2013

116/215



Contains three body system values:

Physiological Systems and Anatomical Regions

Circulatory

Indwelling Device

RLM.MD 06/11

ICD-10-PCS

116


8/12/2019 ICD-10-PCS 2013

117/215



Physiological Systems and Anatomical Regions

Introduction: Putting in a therapeutic, diagnostic,nutritional, physiological orprophylactic substance except bloodor blood products

Irrigation: Putting in or on a cleansingsubstance

RLM.MD 06/11

ICD-10-PCS

117


8/12/2019 ICD-10-PCS 2013

118/215

Root Operation

(Character 3)

Circulatory System

Transfusion: Putting in blood or blood

products

RLM.MD 06/11

ICD-10-PCS

118


8/12/2019 ICD-10-PCS 2013

119/215

Root Operation

(Character 3)

Indwelling Device

Irrigation: Putting in or on a cleansing

substance

RLM.MD 06/11

ICD-10-PCS

119


8/12/2019 ICD-10-PCS 2013

120/215


Body Part(Character 4)

For Introduction, the body part specifies where

the procedure occurs and not necessarily the site

where the substance introduced has an effect

For Irrigation, the body part specifies the site of

the irrigation

RLM.MD 06/11

ICD-10-PCS

120


8/12/2019 ICD-10-PCS 2013

121/215

Approach

(Character 5) Approach uses values defined in the Medical and Surgical

section

The approach value for intradermal, subcutaneous andintramuscular introductions (i.e., injections) is

percutaneous

If a catheter is used to introduce a substance into a site

within the circulatory system, the approach value is alsopercutaneous

RLM.MD 06/11

ICD-10-PCS

121


8/12/2019 ICD-10-PCS 2013

122/215

Substance(Character 6)

Substances are specified in broad

categories Substance values depend on body part

RLM.MD 06/11

ICD-10-PCS

122


8/12/2019 ICD-10-PCS 2013

123/215

Substance

Physiological System & Anatomical Regions

Antineoplastic

Thrombolytic

Anti-infective

Anti-inflammatory

Radioactive Substance

Nutritional Substance

Electrolytic and Water BalanceSubstance

Irrigating Substance

Dialysate

Local Anesthetic

Regional Anesthetic

Inhalation Anesthetic

Gas

Contrast Agent

Fertilized Ovum

Sperm

Pigment

Platelet Inhibitor

Destructive Agent

RLM.MD 06/11

ICD-10-PCS

123

Examples:


b

8/12/2019 ICD-10-PCS 2013

124/215

Substance

Circulatory SystemExamples:

Serum Albumin

Frozen Plasma

Fresh Plasma

Plasma Cryoprecipitate

Red Blood Cells

Stem Cells, Hematopoietic

RLM.MD 06/11

ICD-10-PCS

124

White Cells

Platelets

Globulin

Fibrinogen

Factor IXBone Marrow


8/12/2019 ICD-10-PCS 2013

125/215

Qualifier

(Character 7)

May further specify a substance

Examples:

High-dose Interleukin-2

Liquid Brachytherapy Isotope

Insulin

RLM.MD 06/11

ICD-10-PCS

125

8/12/2019 ICD-10-PCS 2013

126/215

8/12/2019 ICD-10-PCS 2013

127/215

Measurement and

Monitoring Section

RLM.MD 06/11

ICD-10-PCS

127

Measurement and Monitoring Section


8/12/2019 ICD-10-PCS 2013

128/215


1stCharacter = Section 2ndCharacter = Physiological System


4th

Character = Body System 5thCharacter = Approach

6thCharacter = Function

7th


RLM.MD 06/11

ICD-10-PCS

128

Measurement and Monitoring

8/12/2019 ICD-10-PCS 2013

129/215

g

Body System

(Character 2)

Contains a single body system value:

Physiological Systems

RLM.MD 06/11

ICD-10-PCS

129


8/12/2019 ICD-10-PCS 2013

130/215

Root Operation

(Character 3)

Measurement: Determining the level of aphysiological or physical

function at a point in time

Monitoring: Determining the level of a

physiological or physicalfunction repetitively over aperiod of time

RLM.MD 06/11

ICD-10-PCS

130


8/12/2019 ICD-10-PCS 2013

131/215

g

Approach(Character 5)

Approach contains values also in the

Medical and Surgical section

Examples:

Percutaneous


Endoscopic

RLM.MD 06/11

ICD-10-PCS

131


8/12/2019 ICD-10-PCS 2013

132/215


Function(Character 6)

Specifies physiological or physical

functions (e.g., nerve conductivity, cardiac

electrical activity, respiratory capacity)

RLM.MD 06/11

ICD-10-PCS

132


Table 4A1 Excerpt

8/12/2019 ICD-10-PCS 2013

133/215

Table 4A1 Excerpt

RLM.MD 06/11

ICD-10-PCS

133

8/12/2019 ICD-10-PCS 2013

134/215

Extracorporeal

Assistance andPerformance Section

RLM.MD 06/11

ICD-10-PCS134

Extracorporeal Assistanceand Performance Section

8/12/2019 ICD-10-PCS 2013

135/215




4th

Character = Body System 5thCharacter = Duration

6thCharacter = Function

7th


RLM.MD 06/11

ICD-10-PCS135

Extracorporeal Assistance

8/12/2019 ICD-10-PCS 2013

136/215


and PerformanceBody System(Character 2)



RLM.MD 06/11

ICD-10-PCS136


d P f

8/12/2019 ICD-10-PCS 2013

137/215

and Performance


Assistance: Taking over a portion of a physiological

function by extracorporeal means

Performance: Completely taking over a physiologicalfunction by extracorporeal means

Restoration: Returning, or attempting to return, aphysiological function to its normalstate by extracorporeal means

RLM.MD 06/11

ICD-10-PCS137


d f

8/12/2019 ICD-10-PCS 2013

138/215

and Performance

Duration(Character 5)

Specifies whether the procedure was a single

occurrence, multiple occurrence, intermittent,or continuous

For respiratory ventilation assistance or

performance, the range of hours is specified(96 hours)

RLM.MD 06/11

ICD-10-PCS138


d f

8/12/2019 ICD-10-PCS 2013

139/215

and Performance

Function

(Character 6)

Specifies the physiological functionassisted or performed (e.g., oxygenation,ventilation)

RLM.MD 06/11

ICD-10-PCS139


8/12/2019 ICD-10-PCS 2013

140/215

p

and PerformanceQualifier

(Character 7)

May specify equipment used in the

procedure (e.g., balloon pump)

RLM.MD 06/11

ICD-10-PCS140

8/12/2019 ICD-10-PCS 2013

141/215

8/12/2019 ICD-10-PCS 2013

142/215

Extracorporeal Therapies Section


8/12/2019 ICD-10-PCS 2013

143/215




4th

Character = Body System 5thCharacter = Duration


7

th


RLM.MD 06/11

ICD-10-PCS143

Extracorporeal Therapies

8/12/2019 ICD-10-PCS 2013

144/215




RLM.MD 06/11

ICD-10-PCS144

Extracorporeal Therapies

R O i

8/12/2019 ICD-10-PCS 2013

145/215

Root Operation

(Character 3)

Contains ten root operation values:

Atmospheric Control Pheresis

Decompression Phototherapy

Electromagnetic Therapy Ultrasound Therapy

Hyperthermia Ultraviolet Light

Hypothermia Therapy

Shock Wave Therapy

RLM.MD 06/11

ICD-10-PCS145

8/12/2019 ICD-10-PCS 2013

146/215

8/12/2019 ICD-10-PCS 2013

147/215

Osteopathic Section


8/12/2019 ICD-10-PCS 2013

148/215

p

1stCharacter = Section 2ndCharacter = Anatomical Regions


4th

Character = Body Region 5thCharacter = Approach

6thCharacter = Method

7

th


RLM.MD 06/11

ICD-10-PCS148

Osteopathic Section

8/12/2019 ICD-10-PCS 2013

149/215



Anatomical Regions

RLM.MD 06/11

ICD-10-PCS149

8/12/2019 ICD-10-PCS 2013

150/215

Osteopathic Section

M h d

8/12/2019 ICD-10-PCS 2013

151/215

Method(Character 6)

Articulatory - Raising

Fascial Release

General Mobilization

High Velocity - Low Amplitude

Indirect

Low Velocity- High Amplitude

Lymphatic Pump

Muscle Energy - Isometric Muscle Energy - Isotonic

Other Method

RLM.MD 06/11

ICD-10-PCS151

8/12/2019 ICD-10-PCS 2013

152/215

Other ProceduresSection

RLM.MD 06/11

ICD-10-PCS152

8/12/2019 ICD-10-PCS 2013

153/215

Other Procedures Section

Root Operation

8/12/2019 ICD-10-PCS 2013

154/215

Root Operation

(Character 3)

Contains a single root operation value

Other Procedures:Methodologies which attempt to remediate or cure a

disorder or disease

RLM.MD 06/11

ICD-10-PCS154

Other Procedures Section

d

8/12/2019 ICD-10-PCS 2013

155/215

Body Region(Character 4)

Contains physiological system and anatomical region values:

Nervous System

Circulatory System

Head and Neck Region Integumentary System and Breast

Musculoskeletal System

Female Reproductive System

Male Reproductive System

Trunk Region

Upper Extremity

Lower Extremity

None

RLM.MD 06/11

ICD-10-PCS155

Miscellaneous Section

Method

8/12/2019 ICD-10-PCS 2013

156/215

Method

(Character 6)

Acupuncture

Therapeutic

Massage

Collection

RLM.MD 06/11

ICD-10-PCS156

Computer Assisted Procedure

Robotic Assisted Procedure

Near Infrared Spectroscopy

Other Method

8/12/2019 ICD-10-PCS 2013

157/215

Chiropractic Section

RLM.MD 06/11

ICD-10-PCS157

Chiropractic SectionCharacter Specification

8/12/2019 ICD-10-PCS 2013

158/215

p

1st

Character = Section 2ndCharacter = Anatomical Regions


4th

Character = Body Region 5thCharacter = Approach

6thCharacter = Method


RLM.MD 06/11

ICD-10-PCS158


8/12/2019 ICD-10-PCS 2013

159/215



Anatomical Regions

RLM.MD 06/11

ICD-10-PCS159


Root Operation

8/12/2019 ICD-10-PCS 2013

160/215

Root Operation

(Character 3)

Contains a single root operation value

Manipulation:Manual procedure that involves a directed thrust to

move a joint past the physiological range of motion,

without exceeding the anatomical limit

RLM.MD 06/11

ICD-10-PCS160


M th d

8/12/2019 ICD-10-PCS 2013

161/215

Method

(Character 6) Non-Manual

Indirect Visceral

Extra-Articular Direct Visceral

Long Lever Specific Contact

Long and Short Lever Specific Contact

Mechanically Assisted

Other Method

RLM.MD 06/11

ICD-10-PCS161

8/12/2019 ICD-10-PCS 2013

162/215

Imaging Section

RLM.MD 06/11

ICD-10-PCS162

Imaging SectionCharacter Specification

8/12/2019 ICD-10-PCS 2013

163/215

1st

Character = Section 2ndCharacter = Body System

3rdCharacter = Root Type

4th

Character = Body Part 5thCharacter = Contrast



RLM.MD 06/11

ICD-10-PCS163

Imaging Section

8/12/2019 ICD-10-PCS 2013

164/215

g g

Contains diagnostic radiology procedures

Nuclear medicine is a separate section

Radiation Oncology is a separate section

Interventional Radiology

The intervention procedure is coded in the Medical

and Surgical section

RLM.MD 06/11

ICD-10-PCS164

Imaging Section

Root Type

8/12/2019 ICD-10-PCS 2013

165/215

Root Type(Character 3)

Plain Radiography

Fluoroscopy

CT Scan

MRI

Ultrasound

RLM.MD 06/11

ICD-10-PCS165

8/12/2019 ICD-10-PCS 2013

166/215

Imaging Section

Root Type Definitions(Character 3)

RLM.MD 06/11

ICD-10-PCS166

Imaging Section

Root Type

8/12/2019 ICD-10-PCS 2013

167/215

Root Type

Plain Radiography

Planar display of an image developed

from the capture of external ionizing

radiation on photographic or

photoconductive plate

RLM.MD 06/11

ICD-10-PCS167

Imaging Section

Root Type

8/12/2019 ICD-10-PCS 2013

168/215

Root Type

Fluoroscopy

Single plane or bi-plane real time display

of an image developed from the capture

of external ionizing radiation on a

fluorescent screen. The image may also

be stored by either digital or analog

means

RLM.MD 06/11

ICD-10-PCS168

Imaging Section

Root Type

8/12/2019 ICD-10-PCS 2013

169/215

Root Type

Computerized Tomography(CT Scan)

Computer-reformatted digital display of

multiplanar images developed from thecapture of multiple exposures of external

ionizing radiation

RLM.MD 06/11

ICD-10-PCS169

Imaging Section

Root Type

8/12/2019 ICD-10-PCS 2013

170/215

RootTypeMagnetic Resonance Imaging

(MRI)

Computer-reformatted digital display of

multiplanar images developed from the

capture of radio-frequency signals emitted

by nuclei in a body site excited within a

magnetic field

RLM.MD 06/11

ICD-10-PCS170

Imaging Section

Root Type

8/12/2019 ICD-10-PCS 2013

171/215

Root TypeUltrasonography

Real time display of images of anatomy or flowinformation developed from the capture ofreflected and attenuated high frequency soundwaves

RLM.MD 06/11

ICD-10-PCS171

Imaging Section

Contrast Material

8/12/2019 ICD-10-PCS 2013

172/215

Contrast Material

(Character 5)

Contrast is differentiated by the

concentration of the contrast material(e.g., high or low osmolar)

RLM.MD 06/11

ICD-10-PCS172

Imaging Section

Qualifier

8/12/2019 ICD-10-PCS 2013

173/215

Q

(Character 6)

Specifies an imaging procedure without

contrast followed by contrast

RLM.MD 06/11

ICD-10-PCS173

8/12/2019 ICD-10-PCS 2013

174/215

Nuclear Medicine

Section

RLM.MD 06/11

ICD-10-PCS174

Nuclear Medicine SectionCharacter Specification

8/12/2019 ICD-10-PCS 2013

175/215

1st



4

th

Character = Body Part 5thCharacter = Radionuclide



RLM.MD 06/11

ICD-10-PCS175

8/12/2019 ICD-10-PCS 2013

176/215

Nuclear Medicine Section

Type Definitions(Character 3)

RLM.MD 06/11

ICD-10-PCS176

Nuclear Medicine

Root Type

8/12/2019 ICD-10-PCS 2013

177/215

Root Type

Planar Imaging

Introduction of radioactive materials into

the body for a single plane display ofimages developed from the capture of

radioactive emissions

RLM.MD 06/11

ICD-10-PCS177

Nuclear Medicine

Root Type

8/12/2019 ICD-10-PCS 2013

178/215

Root TypeTomographic (Tomo) Imaging


the body for three dimensional display ofimages developed from the capture of


RLM.MD 06/11

ICD-10-PCS178

Nuclear Medicine

Root Type

8/12/2019 ICD-10-PCS 2013

179/215

Root Type

Positron EmissionTomographic (PET) Imaging


the body for three dimensional display of

images developed from the simultaneous

capture, 180 degrees apart, of radioactive

emissions

RLM.MD 06/11

ICD-10-PCS179

Nuclear Medicine

Root Type

8/12/2019 ICD-10-PCS 2013

180/215

Root Type

Nonimaging Uptake


the body for measurements of organfunction, from the detection of radioactive

emissions

RLM.MD 06/11

ICD-10-PCS180

Nuclear Medicine

Root Type

8/12/2019 ICD-10-PCS 2013

181/215

Root Type

Nonimaging Probe

Introduction of radioactive materials into the

body for the study of distribution and fate of

certain substances by the detection of

radioactive emissions; or, alternatively,

measurement of absorption of radioactive

emissions from an external source

RLM.MD 06/11

ICD-10-PCS181

Nuclear Medicine

Root Type

8/12/2019 ICD-10-PCS 2013

182/215

Root TypeNonimaging Assay


the body for the study of body fluids andblood elements, by the detection of


RLM.MD 06/11

ICD-10-PCS182

Nuclear Medicine

R t T

8/12/2019 ICD-10-PCS 2013

183/215

Root TypeSystemic Therapy

Introduction of unsealed radioactive

materials into the body for treatment

RLM.MD 06/11

ICD-10-PCS183

Nuclear Medicine Section

Body Part

8/12/2019 ICD-10-PCS 2013

184/215

Body Part(Character 4)

Indicates the body part or region to the

degree of specificity that is usual andappropriate for the section

Regional (e.g., lower extremity veins) and

combination body parts (e.g., liver andspleen) are commonly used

RLM.MD 06/11

ICD-10-PCS184

Nuclear Medicine SectionRadionuclide

8/12/2019 ICD-10-PCS 2013

185/215

Radionuclide

(Character 5)

Character 5 is the source of the radiation An Other Radionuclide option is included for

new FDA approved radiopharmaceuticals

RLM.MD 06/11

ICD-10-PCS185

8/12/2019 ICD-10-PCS 2013

186/215

Radiation Oncology

Section

RLM.MD 06/11

ICD-10-PCS186

Radiation Oncology Section


8/12/2019 ICD-10-PCS 2013

187/215

1st



4thCharacter = Treatment Site

5thCharacter = Modality Qualifier

6thCharacter = Isotope


RLM.MD 06/11

ICD-10-PCS187


Root Type

8/12/2019 ICD-10-PCS 2013

188/215

(Character 3)

Classified by the basic mode of radiation

delivery used:Beam Radiation

Brachytherapy

Stereotactic RadiosurgeryOther Radiation

RLM.MD 06/11

ICD-10-PCS188


Treatment Site

8/12/2019 ICD-10-PCS 2013

189/215

Treatment Site(Character 4)

Specifies the body part that is the target of

the radiation therapy

RLM.MD 06/11

ICD-10-PCS189


Modality Qualifier

8/12/2019 ICD-10-PCS 2013

190/215

Modality Qualifier(Character 5)

Further specifies the type of radiation used:

photons

electrons

heavy particles

contact radiation

RLM.MD 06/11

ICD-10-PCS190


Isotope

8/12/2019 ICD-10-PCS 2013

191/215

Isotope(Character 6)

Specifies the isotope administered in

oncology treatments

RLM.MD 06/11

ICD-10-PCS191

8/12/2019 ICD-10-PCS 2013

192/215

Physical Rehabilitation and

Diagnostic AudiologySection

RLM.MD 06/11

ICD-10-PCS192

Physical Rehabilitation andDiagnostic AudiologySection


8/12/2019 ICD-10-PCS 2013

193/215

1st

Character = Section 2ndCharacter = Section Qualifier


4thCharacter = Body System and Region

5thCharacter = Type Qualifier

6thCharacter = Equipment


RLM.MD 06/11

ICD-10-PCS193

Physical Rehabilitation andDiagnostic Audiology

8/12/2019 ICD-10-PCS 2013

194/215

Root Type(Character 3)

Treatment:

Use of specific activities or methods to develop, improveand/or restore the performance of necessary functions,compensate for dysfunction and /or minimize debilitation

Assessment:

Includes a determination of the patients diagnosis whenappropriate, need for treatment, planning for treatment,periodic assessment and documentation related to theseactivities

RLM.MD 06/11

ICD-10-PCS194

8/12/2019 ICD-10-PCS 2013

195/215


8/12/2019 ICD-10-PCS 2013

196/215

Body System and Region(Character 4)

Body Systems Neurological System

Circulatory System Respiratory System

Integumentary System

Musculoskeletal System

Genitourinary System

Body Regions- Head and Neck

- Upper Back/Upper Extremity

- Lower Back/Lower Extremity

- Whole Body RLM.MD 06/11ICD-10-PCS

196


8/12/2019 ICD-10-PCS 2013

197/215

Type Qualifier(Character 5)

Specifies the precise test or method

employed

Examples:

Therapeutic exercise treatment

Dressing or transfer assessmentProsthesis fitting

Transfer caregiver trainingRLM.MD 06/11

ICD-10-PCS197

Physical Rehabilitation and

Diagnostic Audiology

8/12/2019 ICD-10-PCS 2013

198/215

Equipment(Character 6)

Specific types of equipment are not listed General categories of equipment are listed

(e.g., physical agents, mechanical

modalities, assistive/adaptive/supportive

devices)

RLM.MD 06/11

ICD-10-PCS198

8/12/2019 ICD-10-PCS 2013

199/215

Mental Health Section

RLM.MD 06/11

ICD-10-PCS199

Mental Health SectionCharacter Specification

8/12/2019 ICD-10-PCS 2013

200/215

1st







RLM.MD 06/11

ICD-10-PCS200

8/12/2019 ICD-10-PCS 2013

201/215


Type Qualifier

8/12/2019 ICD-10-PCS 2013

202/215

Type Qualifier(Character 4)

Type qualifier provides additional

specificity

Not all types have type qualifier

RLM.MD 06/11

ICD-10-PCS202


Type Qualifier

8/12/2019 ICD-10-PCS 2013

203/215

(Character 4)Example:

Psychological Tests

Developmental

Personality and Behavioral

Intellectual and Psychoeducational

Neuropsychological Neurobehavioral and Cognitive Status

RLM.MD 06/11

ICD-10-PCS203


Qualifier

8/12/2019 ICD-10-PCS 2013

204/215

(Character 5 - 7 )

Have a value of Z None

RLM.MD 06/11

ICD-10-PCS204

8/12/2019 ICD-10-PCS 2013

205/215

Substance Abuse

Treatment Section

RLM.MD 06/11

ICD-10-PCS205

Substance Abuse SectionCharacter Specification

st

8/12/2019 ICD-10-PCS 2013

206/215

1

st







RLM.MD 06/11

ICD-10-PCS206

Substance Abuse TreatmentRoot Type

8/12/2019 ICD-10-PCS 2013

207/215

(Character 3)

Detoxification Services

Individual Counseling

Group Counseling

Individual Psychotherapy

Family Counseling

Medication Management

Pharmacotherapy

RLM.MD 06/11

ICD-10-PCS207

Substance Abuse Treatment

Type Qualifier

8/12/2019 ICD-10-PCS 2013

208/215

yp

(Character 4)

Type qualifier provides additional

specificity

Not all types have type qualifier

RLM.MD 06/11

ICD-10-PCS208


Type Qualifier

8/12/2019 ICD-10-PCS 2013

209/215

yp Q

(Character 4)Example:

Pharmacotherapy

Nicotine Replacement Therapy

Methadone Maintenance LAAM

Antabuse

Naltrexone

Naloxone

Clonidine

Bupropion

Psychiatric Medications

Other Replacement MedicationRLM.MD 06/11

ICD-10-PCS209


Qualifier

8/12/2019 ICD-10-PCS 2013

210/215

(Character 5 - 7 )

Have a value of Z None

RLM.MD 06/11

ICD-10-PCS210

8/12/2019 ICD-10-PCS 2013

211/215

ICD-10-PCS Testing

RLM.MD 06/11

ICD-10-PCS211

ICD-10-PCS Testing

8/12/2019 ICD-10-PCS 2013

212/215

Tested by Clinical Data Abstraction Centers(CDACs)FMAS, Columbia, MD

DynKePRO, York, PA Coded 5,000 records

Offered feedback on issues found

Suggested improvements

Additional comparison test of 100 records

Additional testing on ambulatory records

RLM.MD 06/11

ICD-10-PCS212

Major Modifications as

a Result of Testing

8/12/2019 ICD-10-PCS 2013

213/215

Limited Not Otherwise Specified (NOS)

options added

Number of approaches reduced

Training manual revised

Index entries added

RLM.MD 06/11

ICD-10-PCS213

Testing Findings

8/12/2019 ICD-10-PCS 2013

214/215

More complete than ICD-9-CM, greater

specificity

Easy to expand the system

Multi-axial structure makes it easier to

analyze

Standardized terminology makes it easier to

use once the coder has initial training

RLM.MD 06/11

ICD-10-PCS214

Testing Findings

8/12/2019 ICD-10-PCS 2013

215/215

Initial training time will be a factor since it

differs significantly from ICD-9-CM

Having all terms defined makes it easier to

teach

Once basic knowledge is acquired, the coder

does not use the index

icd-10-pcs 2013

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