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ICD-10-PCS Reference Manual

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ICD-10-PCS Reference Manual ICD-10-PCS Reference Manual 3 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 ICD-10-PCS Reference Manual Page iii Table of Contents 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—Root operation B .............................................................................................. 40 Coding note: Bone marrow and endometrial biopsies ................................................ 40 Example: Excision of sebaceous cyst (right buttock) ................................................. 40 Coding exercises ........................................................................................................ 41 Resection—Root operation T ............................................................................................ 41 Coding note: Lymph nodes ......................................................................................... 42 Example: Right hemicolectomy .................................................................................. 42 Coding note: Anastomotic technique .......................................................................... 42 Coding exercises ........................................................................................................ 42 Detachment—Root operation 6......................................................................................... 43 Detachment qualifiers ................................................................................................. 43 Example: Fifth toe ray amputation .............................................................................. 44 Coding exercises ........................................................................................................ 45 Coding note: Qualifier value ....................................................................................... 45 Destruction—Root operation 5 .......................................................................................... 45 Example: Radiofrequency coagulation of the trigeminal nerve .................................. 46 Coding note: Approach value ..................................................................................... 46 Coding exercises ........................................................................................................ 46 Extraction—Root 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—Root operation
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