Development of the ICD-10 Procedure Coding System (ICD-10-PCS)

Richard F. Averill, M.S., Robert L. Mullin, M.D., Barbara A. Steinbeck, RHIT, Norbert I. Goldfield, M.D, Thelma M. Grant, RHIA

The International Classification of Dis- Introduction eases 10th Revision Procedure Classifica- tion System (ICD-10-PCS) has been Volume 3 of the International Classifica- developed as a replacement for Volume 3 tion of Diseases 9th Revision Clinical of the International Classification of Dis- Modification (ICD-9-CM) has been used in eases 9th Revision. The development of the U.S. for the reporting of inpatient pro- ICD-10-PCS was funded by the U.S. cedures since 1979. The structure of Vol- Health Care Financing Administration. ume 3 of ICD-9-CM has not allowed new ICD-10-PCS has a multi-axial seven char- procedures associated with rapidly chang- acter alphanumerical code structure which ing technology to be effectively incorpo- provides a unique code for all substantially rated as new codes. As a result, in 1992 different procedures and which allows new the U.S. Health Care Financing Adminis- procedures to be easily incorporated as tration (HCFA) funded a project to produce new codes. ICD-10-PCS was under devel- a preliminary design for a replacement for opment for over five years and the initial Volume 3 of ICD-9-CM. After a review of the preliminary design, HCFA in 1995 draft was formally tested and evaluated by awarded 3M Health Information Systems a an independent contractor. The final ver- three year contract to complete the devel- sion of the ICD-10-PCS was released in opment of a replacement system. The new the Spring of 1998. The design, develop- system is named ICD-10 Procedure Cod- ment and testing of ICD-10-PCS are dis- ing System (ICD-10-PCS). cussed. The development of ICD-10-PCS has ______four major objectives:

The ICD-10-PCS is being developed with the support of the Health Care Financing Administration, under contract Nos. 90-1138, 91-22300 and Completeness 500-95-0005 to 3M Health Information Systems. Consultation in the development of ICD-10-PCS was provided by Donn G. Duncan, M.D. There should be a unique code for all and Gerard M. Doherty, M.D. The coding staff of the Division of Prospec- tive Payment System, Office of Hospital Policy, Bureau of Policy Devel- substantially different procedures. In opment of the Health Care Financing Administration, DHHS, provided Volume 3 of ICD-9-CM, procedures on ongoing review and evaluation during the development of the ICD-10- PCS: Patricia E. Brooks, Ann Bowling Fagan, Amy L. Gruber. A wide different body parts, with different range of physician specialty societies, individual clinicians, health care approaches, or of different types are professionals and researchers provided valuable input into the research. The Tabular List, Code Descriptions, and Index were computer gener- sometimes assigned to the same code. ated based on an expert system designed by: Yvette Wang, Laurence Gregg, Enes Elia, and David Gannon. Address correspondence and Expandability requests for reprints to Richard F. Averill, M.S., Senior Director, Clinical Research Department, 3M Health Information Systems, 100 Barnes Road, Wallingford, CT 06492. Robert L. Mullin, M.D., Barbara Steinbeck, As new procedures are developed the ART, Norbert I. Goldfield, M.D., Thelma Grant, RRA, are with 3M Health Information Systems, 3M Health Care. The opinions expressed are solely structure of ICD-10-PCS should allow those of the authors and do not necessarily reflect the views or policy them to be easily incorporated as unique positions of 3M Health Information Systems or the Health Care Financing Administration. codes.

3M HIS Research Report 4-98 1 Multi-axial information available in the medical record ICD-10-PCS should have a multi-axial to support the specificity required by ICD- structure with each code character having 10-PCS. the same meaning within a specific Limited Use of Not Elsewhere Classified procedure section and across procedure (NEC) Option sections to the extent possible. ICD-9-CM will often provide a “not Standardized Terminology elsewhere classified” option. All possible ICD-10-PCS should include definitions components of a procedure are specified of the terminology used. While the in ICD-10-PCS, thus, in general, there is meaning of specific words can vary in no need for a “not elsewhere classified” common usage, ICD-10-PCS should not option. However, new devices are include multiple meanings for the same frequently being developed and therefore, term and each term must be assigned a for devices, it is necessary to have a “not specific meaning. elsewhere classified” option that can be used until the new device can be explicitly If these four objectives are accom- added to the coding system. Likewise, an plished, then ICD-10-PCS should enhance NEC option is included in the nuclear the ability of health information coders to medicine section that can be used for determine accurate codes with minimal newly approved radiopharmaceuticals effort. until they can be explicitly added to the In the development of ICD-10-PCS, coding system. there were several general guidelines that Level of Specificity were followed: Based on the combinations of the seven Diagnostic Information is Not Included in alphanumeric characters, all possible Procedure Description procedures were defined. Frequency of When procedures are performed for occurrence was not a consideration in the specific diseases or disorders, the disease development of the system. A code was or disorder is not specified. Thus, there created for any procedure that could be are no separate codes for procedures for performed. aneurysms, cleft lip, strictures, neoplasms, ICD-10-PCS has a seven character hernias, etc. The diagnosis codes and not alphanumeric code structure. Each char- the procedure codes contain the specific acter has up to 34 different values. The information regarding the nature of the ten digits 0-9 and the 24 letters A-H,J-N disease or disorder. and P-Z comprise each character. The let- Explicit Not Otherwise Specified (NOS) ters O and I are not used in order to avoid Options are Not Provided confusion with the digits 0 and 1. ICD-9-CM will often provide a “not Procedures are divided into sections otherwise specified” option. Explicit NOS that relate to the general type of procedure options are not provided in ICD-10-PCS. A (e.g., medical and surgical, imaging, etc.). minimal level of specificity is always The first character of the procedure code required for each component of the always specifies the section. The sections procedure. For each component of the are shown in Table 1. procedure there are ICD-10-PCS coding rules that specify how the procedure The second through seventh characters should be coded when there is insufficient have a standard meaning within each sec-

2 3M HIS Research Report 4-98 Sections direct look up of each code and provides a 0 Medical and Surgical short description of each code. 1 Obstetrics Tabular List in ICD-10-PCS Manual 2 Placement 3 Administration The Tabular List in ICD-10-PCS has a 4 Measurement and Monitoring very different organization than ICD-9-CM. 5 Imaging Each page in the Tabular List is composed 6 Nuclear Medicine of grids which specify the valid combina- 7 Radiation Oncology tions of character values that comprise a 8 Osteopathic particular procedure code. Table 2 shows 9 Rehabilitation and Diagnostic Audiology a portion of a page from the Tabular List. B Extracorporeal Assistance and Performance The upper portion of each grid contains a C Extracorporeal Therapies description of the first two or three charac- D Laboratory ters of the procedure code. For example, F Mental Health for procedures in the medical and surgical G Chiropractic section the first three characters are the H Miscellaneous name of the section, the body system and the root operation being performed. Table 1: Sections In ICD-10-PCS characters 027 would tion but may have different meanings indicate that the grid refers to the medical across sections. and surgical section (0) of the body sys- In most sections, one of the characters tem heart & great vessels (2) and a root specifies the precise type of procedure operation of dilation (7). As shown in Table being performed (e.g., excision, resection, 2 the root operation (i.e., dilation) is fol- etc.), while the other characters specify lowed by its definition. additional information such as the body The lower portion of the grid specifies all part on which the procedure is being per- the valid combinations of characters four formed. In the ICD-10-PCS the term “pro- through seven. The four columns in the cedure” is used to refer to the complete grid represent the last four characters and specification of the seven characters. for the medical and surgical section are labeled Body Part, Approach, Device and ICD-10-PCS Manual Qualifier, respectively. Each row in the grid defines the valid combinations of charac- In the ICD-10-PCS system, the ICD-10- ters four through seven. The Tabular List PCS codes are described in three sepa- contains only combinations of characters rate divisions. that represent a valid procedure. Combi- Tabular Listing nations of characters that do not constitute Index a valid procedure are not contained in the List of Codes Tabular List. The Index allows codes to be located by The grid in Table 3 generates 48 unique an alphabetic look up. The Index entry will procedure codes. For example, code refer to a specific location in the Tabular 02705DZ represents the procedure for List. Reference to the Tabular List is dilation of one coronary artery using an always necessary in order to obtain the intraluminal device by a percutaneous complete code. The list of codes allows a intraluminal approach (i.e., percutaneous

3M HIS Research Report 4-98 3 0: Medical and Surgical 2: Heart and Great Vessels 7: Dilation: Expanding the orifice or the lumen of a tubular body part Body Part Approach Device Qualifier Character 4 Character 5 Character 6 Character 7 0 Coronary Artery, One 1 Open Intraluminal DIntraluminal Device Z None 1 Coronary Arteries, Two 2 Open Intraluminal Endoscopic Y Device NEC 2 Coronary Arteries, Three 5 Percutaneous Intraluminal Z None 3 Coronary Arteries, Four or 6 Percutaneous Intraluminal Endoscopic More Table 2: Grid from the Tabular list specifies the valid combinations of characters 4 through 7 for the medical and surgical procedure dilation of the heart and great vessels (027) transluminal coronary angioplasty with intraluminal device can be found in the stent). Index under dilation, or any synonym of List of Codes dilation (e.g., angioplasty). Once the desired term is located in the Index, the The actual codes that result from the Index specifies the first three or four char- first body part (i.e., one coronary artery) in acters of the code followed by three peri- the grid for dilation of heart and great ves- ods (e.g., 0270...). Each entry in the sels are listed in Table 3. The 12 codes Tabular List refers to the first three charac- listed in Table 3 are examples of entries in ters of the code (e.g., 027). Based on the the List of Codes. Each code has a first three characters of the code obtained description that is complete and easy to from the Index, the corresponding entry in read. the Tabular List can be located. The Tabu- Index lar List is then used to obtain the complete code by specifying the possible combina- The Index allows codes to be located tions of the last four characters. based on an alphabetic look up. Codes can be found in the index based on the Medical and Surgical Procedures type of procedure being performed. Thus, The seven characters for medical and sur- the code for a percutaneous intraluminal gical procedures have the following mean- dilation of the coronary arteries with an ing:

02701DZ Dilation, Coronary Artery, One, Open Intraluminal with Intraluminal Device 02701YZ Dilation, Coronary Artery, One, Open Intraluminal with Device NEC 02701ZZ Dilation, Coronary Artery, One, Open Intraluminal 02702DZ Dilation, Coronary Artery, One, Open Intraluminal Endoscopic with Intraluminal Device 02702YZ Dilation, Coronary Artery, One, Open Intraluminal Endoscopic with Device NEC 02702ZZ Dilation, Coronary Artery, One, Open Intraluminal Endoscopic 02705DZ Dilation, Coronary Artery, One, Percutaneous Intraluminal with Intraluminal Device 02705YZ Dilation, Coronary Artery, One, Percutaneous Intraluminal with Device NEC 02705ZZ Dilation, Coronary Artery, One, Percutaneous Intraluminal 02706DZ Dilation, Coronary Artery, One, Percutaneous Intraluminal Endoscopic with Intraluminal Device 02706YZ Dilation, Coronary Artery, One, Percutaneous Intraluminal Endoscopic with Device NEC 02706ZZ Dilation, Coronary Artery, One, Percutaneous Intraluminal Endoscopic Table 3: Code descriptions for dilation of one coronary artery (0270)

4 3M HIS Research Report 4-98 assigned multiple body system categories. 12 3 4567 For example, body system categories K (Muscles), L (Tendons), M (Bursa, Liga- Section Root Operation Approach Qualifier ments, Fascia), N (Head and Facial Body System Body Part Device Bones), P (Upper Bones), Q (Lower Bones), R (Upper Joints) and S (Lower Joints) are subsystems of the Musculosk- SECTION eletal system. The medical and surgical section consti- Body Systems tutes the vast majority of procedures that 0 Central Nervous System would normally be reported in an inpatient 1 Peripheral Nervous System setting. Medical and surgical procedures 2 Heart and Great Vessels have the first character specifying the sec- 3 Upper Arteries tion designated with the number “0”. 4 Lower Arteries BODY SYSTEM 5 Upper Veins 6 Lower Veins The second character indicates the gen- 7 Lymphatic and Hemic System eral body system (e.g., gastrointestinal). 8Eye The third character indicates the root oper- 9 Ear, Nose, Sinus ation which specifies the objective of the B Respiratory System procedure (e.g., repair). The fourth char- C Mouth and Throat acter indicates the specific part of the body D Gastrointestinal System system on which the procedure was per- F Hepatobiliary System and Pancreas formed (e.g., duodenum). The fifth charac- G Endocrine System H Skin and Breast ter indicates the approach used to reach J Subcutaneous Tissue the site of the procedure (e.g., open). The KMuscles sixth character indicates whether any L Tendons device was used in the procedure (e.g., M Bursa, Ligaments, Fascia synthetic substitute). The seventh charac- N Head and Facial Bones ter is a qualifier that has a unique meaning P Upper Bones for individual procedures. For example, Q Lower Bones the qualifier can be used to identify the R Upper Joints second site involved in a bypass. Charac- S Lower Joints ters 1-4 must always be assigned a pre- T Urinary System cise value. The approach (character 5), V Female Reproductive System the device (character 6) and the qualifier W Male Reproductive System (character 7) are not applicable to all pro- X Anatomical Regions Y Upper Extremities cedures. The letter Z is used for charac- Z Lower Extremities ters 5, 6 and 7 to indicate that an approach, device or qualifier was not Table 4: Medical and Surgical Body Systems applicable for a specific procedure. ROOT OPERATIONS The body systems for medical and surgi- cal procedures are specified in the second The root operation is specified in the character and are shown in Table 4. In third character. In the medical and surgical order to provide necessary body parts section there are 30 different root opera- detail some traditional body systems are tion terms as shown in Table 5.The root

3M HIS Research Report 4-98 5 Root Operation Definition Alteration Modifying the natural anatomical structure of a body part without affecting the function of the body part Bypass Altering the route of passage of the contents of a tubular body part Change Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane Control Stopping, or attempting to stop, postprocedural bleeding Creation Making a new structure that does not physically take the place of a body part Destruction Eradicating all or a portion of a body part Detachment Cutting off all or a portion of an extremity Dilation Expanding the orifice or the lumen of a tubular body part Division Separating, without taking out, a body part Drainage Taking or letting out fluids and/or gases from a body part Excision Cutting out or off, without replacement, a portion of a body part Extirpation Taking or cutting out solid matter from a body part Extraction Taking out or off all or a portion of a body part Fragmentation Breaking down solid matter in a body part Fusion Joining together portions of an articular body part rendering the articular body part immobile Insertion Putting in a non biological appliance that monitors, assists, performs or prevents a physiologi- cal function but does not physically take the place of a body part Inspection Visually and/or manually exploring a body part Map Locating the route of passage of electrical impulses and/or locating functional areas in a body part Occlusion Completely closing the orifice or lumen of a tubular body part Reattachment Putting back in or on all or a portion of a body part Release Freeing a body part Removal Taking out or off a device from a body part Repair Restoring to the extent possible, a body part to its natural anatomic structure Replacement Putting in or on biological or synthetic material that physically takes the place of all or a portion of a body part Reposition Moving to its normal location or other suitable location all or a portion of a body part Resection Cutting out or off, without replacement, all of a body part Restriction Partially closing the orifice or lumen of a tubular body part Revision Correcting a portion of a previously performed procedure Transfer 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 Transplantation Putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part

Table 5: Medical and Surgical Root Operation Definitions

6 3M HIS Research Report 4-98 operation specifies the underlying objec- BODY PART tive of the procedure. Each root operation The body part is specified in the fourth is given a very precise definition. For character. The body part indicates the example, the term insertion is used for put- specific part of the body system on which ting in or on devices. If a device is taken the procedure was performed (e.g., out but no equivalent device is put in then duodenum). the root operation term removal is used. The term removal is only used for taking APPROACH out or off devices. The root operation term The technique used to reach the site of the extirpation is used when solid matter such procedure (i.e., approach) is specified in as a foreign body, embolus, clot, thrombus the fifth character. There are 13 different or stone is taken out of a body part without approaches as shown in Table 7. taking out any of the body part. The root The approach is comprised of four com- operation term excision is used to indicate ponents: the access location, method, that a portion of a body part was cut out, type of instrumentation and route. while the root operation term resection is used to indicate that all of a body part was Access Location cut out. If the body part that is cut out has For operations performed on an internal biological or synthetic material substituted body site, the access location specifies the for it then the root operation term replace- external body site through which the ment is used. If the body part that is cut internal site of the operation is reached. out has a living body part from a donor put There are two possible access locations: in its place then the root operation term skin or mucous membrane and an transplantation is used. The above exam- external orifice. The skin or mucous ples of root operation terminology illus- membrane can be cut through or trates the precision used to define these punctured by instruments in order to reach terms. There is always a clear distinction the internal site of the operation. The made regarding the differences between internal site of an operation can also be each root operation term. reached through an external orifice. External orifices can be natural (e.g., A root operation must also constitute a mouth) or artificial (e.g., colostomy stoma). complete procedure. The term anastomo- Method sis is not a root operation since it is a The method specifies how the external means of joining and is an integral part of body site is entered. An open method another procedure such as a bypass or a involves cutting through the external body resection. An anastomosis can never be layer or lining of an orifice and any other performed as a stand alone procedure. intervening body layers necessary to Similarly, incision is not a root term since it expose the internal site of the operation. is a means of opening and is always an An instrumental method involves the entry integral part of another procedure. of instrumentation through the access location in order to reach the internal site Appendix A provides additional detail on of the procedure. Instrumentation can be the root operations and Appendix B com- introduced by puncture or minor incision or pares all root operations for the medical through an external orifice. The puncture and surgical section and provides an or minor incision used to introduce the example of each root operation. instrumentation does not constitute an

3M HIS Research Report 4-98 7 Approach Definition

Open Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the operation

Open Intraluminal Cutting through the skin or mucous membrane and any other body layers necessary to expose a tubular body part and introduction of instrumentation into the lumen to reach the site of the operation

Open Intraluminal Endo- Cutting through the skin or mucous membrane and any other body layers necessary to scopic expose a tubular body part and introduction of instrumentation into the lumen to reach and visualize the site of the operation

Percutaneous Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the operation

Percutaneous Endoscopic Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the operation

Percutaneous Intraluminal Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach a tubular body part and intro- duction of instrumentation into the lumen to reach the site of the operation

Percutaneous Intralumi- Entry, by puncture or minor incision, of instrumentation through the skin or mucous nal Endoscopic membrane and any other body layers necessary to reach a tubular body part and intro- duction of instrumentation into the lumen to reach and visualize the site of the operation

Transorifice Intraluminal Entry of instrumentation through a natural or artificial external orifice into the lumen of the connected tubular body part to reach the site of the operation

Transorifice Intraluminal Entry of instrumentation through a natural or artificial external orifice into the lumen of Endoscopic the connected tubular body part to reach and visualize the site of the operation

Open With Cardiopulmo- Cutting through the skin or mucous membrane and any other body layers necessary to nary Bypass expose the site of the operation with the use of cardiopulmonary bypass during a por- tion of the procedure

Open With Inflow Cutting through the skin or mucous membrane and any other body layers necessary to Occlusion expose the site of the operation with the use of inflow occlusion during a portion of the procedure

Open With Temporary Cutting through the skin or mucous membrane and any other body layers necessary to Shunt expose the site of the operation with the use of a temporary shunt during a portion of the procedure

None Procedures performed directly on the skin or mucous membrane and procedures per- formed indirectly by the application of external force through the skin or mucous membrane

Table 6: Medical and Surgical Approach Definitions

8 3M HIS Research Report 4-98 open approach since it does not expose DEVICE the site of the procedure or expose any The device is specified in the sixth char- tubular body part. An approach can acter and is only used to specify devices involve both methods. For example, a that remain after the procedure is com- procedure can include an open method to pleted. There are four general types of expose a tubular body part followed by the devices: introduction of instrumentation into the tubular body part. 1. Biological or synthetic material that Type of Instrumentation takes the place of all or a portion of a Instrumentation may include the body part (e.g, skin grafts and joint capability to visualize the site of the prosthesis). operation. For example, the 2. Biological or synthetic material that instrumentation used to perform a assists or prevents a physiological sigmoidoscopy permits the internal site of function (e.g., IUD). the operation to be visualized while the 3. Therapeutic material that is not instrumentation used to perform a needle absorbed by, eliminated by, or biopsy of the liver does not. The term incorporated into a body part (e.g., endoscopic is used to refer to radioactive implant). Therapeutic instrumentation that permits a site to be materials that are considered devices visualized. can always be removed. Route 4. Mechanical or electronic appliances Instrumental methods may involve the used to assist, monitor, take the place passage of instrumentation into the lumen of or prevent a physiological function of a tubular body part in order to reach the (e.g., diaphragmatic pacemaker, internal site of the operation. An orthopedic pins). intraluminal route indicates that Devices can be used with the root oper- instrumentation was passed into the ations alteration, bypass, change, cre- lumen of a tubular body part. ation, dilation, drainage, fusion, insertion, Operations performed directly on the occlusion, reattachment, removal, repair, skin or mucous membrane constitute an replacement, restriction and revision. external surface and therefore, the Instruments that describe how a proce- approach is none (e.g., skin excision). dure is performed are not specified in the Procedures performed indirectly by the device character. The approach character application of external force also constitute specifies whether instrumentation is used an external site and the approach is none to reach or to reach and visualize the site (e.g., closed repair of fracture). Table 6 of the procedure. If the objective of the contains a definition of each approach. procedure is to put in the device, then the Appendix C compares the components of root operation is insertion. If the device is each different approach along with an put in as a part of a procedure that has an example of each approach. For cardiovas- underlying objective other than the inser- cular procedures there are three additional tion of the device, then the root operation open approaches which specify whether corresponding to the underlying objective cardiopulmonary bypass, inflow occlusion of the procedure is used with the device or a temporary shunt was used during the specified in the device character. Thus, procedure. even if the repair of a bone includes put-

3M HIS Research Report 4-98 9 ting in a fixation device, the root operation Code Based on Objective of Procedure is repair and not insertion. Materials which The root term used to describe a are incidental to a procedure such as clips, procedure is based on the objective of the ligatures and sutures are not specified in procedure. Thus, if a procedure is the device character. Since new devices performed in order to take out a foreign can be developed a “device NEC” option is body, then the procedure is coded as an provided. extirpation. Dilating the urethra would be QUALIFIER coded as dilation since the objective of the procedure is to dilate the urethra. If the The qualifier is specified in the seventh dilation of a urethra includes putting in an character. The qualifier has a unique intraluminal device, the root operation meaning for individual procedures. For remains a dilation and not an insertion of example, the qualifier can be used to iden- the intraluminal device since the tify the second site included in a bypass. underlying objective of the procedure is the dilation of the urethra. Guidelines for Medical and Surgical Combination Procedures are Coded Section Separately If a procedure involves distinct parts, In developing the medical and surgical then multiple codes are used. For procedure codes, there were several spe- example, the obtaining of the vein graft cific guidelines that were followed: used for coronary bypass surgery is coded Composite Terms are not Root Operations as a separate procedure. Root operations describe only the Revisions of Procedures underlying objective of the procedure A revision of a procedure is doing over itself. Thus, composite terms such as again a portion of a previously performed colonoscopy and sigmoidectomy are not procedure that has failed to function as root terms since they specify multiple intended. Revisions do not include the aspects of a procedure. A diagnostic complete doing over again of the colonoscopy is a composite of the root procedure which is considered the same operation inspection (visual exploration), as the original procedure. Revisions also the body part (colon) and the instrument do not include the correction of used to visualize the site of the procedure complications that do not require the doing (colonoscope). The precise part of the over again of a portion of the original gastrointestinal tract which was inspected procedure such as the control of bleeding. would be specified by the body part Revision is a root operation term. (character 4). A partial sigmoidectomy is a Revisions can be done on a previously composite of the root operation excision performed alteration, bypass, creation, and the body part sigmoid. A partial detachment, excision, fusion, insertion, sigmoidectomy would be coded as an occlusion, reattachment, repair, excision (cut out, without replacement, a replacement, reposition, resection, portion of a body part) at the body part, restriction, transfer and transplantation. sigmoid. While the terms colonoscopy and The specification of the original operation sigmoidectomy would be in the Index they on which the revision is being performed is would not constitute root entries in the identified in the qualifier character. Tabular List. Revisions can be performed on any

10 3M HIS Research Report 4-98 procedure which includes a device except approach (8), without device (Z) and with the root operation change. Revisions are qualifier diagnostic (X). frequently performed on implanted Tracheostomy: 0B110F5 mechanical appliances (e.g., diaphragmatic pacemakers), or materials Medical and surgical section (0), body used in replacements or repairs (e.g., system respiratory (B), root operation synthetic substitute). Thus, revision bypass (1), body part trachea (1), open encompasses the repositioning and fixing approach (0), with tracheostomy device of malfunctions in devices. Revisions can (F) and qualifier opening to the skin (5). also be performed on any procedure which does not include a device but does Obstetrics include an anastomosis (e.g., resection). Specification of Approach The seven characters for the obstetrics section have the same meaning as in the Many procedures can be accomplished medical and surgical section. by different approaches. Except for procedures on the skin or mucous 12 3 4567 membrane, a specification of the approach is always required. Section Root Operation Approach Qualifier

Body System Body Part Device Examples of procedures coded in ICD- 10-PCS Obstetrical procedures have the first character specifying the section desig- The following are several examples of nated with the number “1”. For the obstet- procedures from the medical and surgical rical section the body system has only one section coded in ICD-10-PCS. value, “0” for pregnancy. The root opera- tions change, drainage, insertion, inspec- Open reduction with internal fixation of left tion, removal, repair, reposition, resection tibia with plate and screws: 0QQH04Z and transplantation are used in the obstet- Medical and surgical section (0), body ric section and have the same meaning as system lower bones (Q), root operation in the medical and surgical section. The repair (Q), body part left tibia (H), open Obstetrics section includes operations approach (0) with internal fixation device performed on the products of conception (4) and without qualifier(Z). only; operations on the pregnant female Laparoscopic appendectomy:0DTJ4ZZ are coded in the medical and surgical sec- tion (e.g., episiotomy). The obstetrics sec- Medical and surgical section (0), body tion also includes two additional root system gastrointestinal (D), root operation operations, abortion and delivery which resection (T), body part appendix (J), are defined as: percutaneous endoscopic approach (4), without device (Z) and without qualifier(Z). Abortion: Artificially terminating a pregnancy

Sigmoidoscopy with biopsy:0DBNZX Assisting the passage of the products of Delivery: Medical and surgical section (0), body conception from the genital canal system gastrointestinal (D), root operation excision (B), body part sigmoid colon (N), A Cesarean Section does not constitute transorifice intraluminal endoscopic an additional root operation since it is a

3M HIS Research Report 4-98 11 resection (i.e., cutting out all of a body specified. Placement procedures have the part). The body parts for the obstetrical first character specifying the section desig- sections are: nated with the number “2”. For the place- Products of conception ment section the body region/orifice has Products of conception, retained only two values indicating either body Products of conception, ectopic region or body orifice. The root operations change and removal are used in the place- The term “products of conception” is ment section and have the same meaning used to refer to all components of a preg- nancy including the fetus, amnion, umbili- as in the medical and surgical section. The cal cord and placenta. There is no placement section also includes five addi- differentiation of the products of concep- tional root operations which are defined as tion based on gestational age. Thus, the follows. specification of the products of conception Compression: Putting pressure on an external body as a zygote, embryo or fetus or the trimes- part Dressing: Putting material on an external body ter of the pregnancy is not part of the pro- part for protection cedure code and would be obtained from Immobilization: Limiting or preventing motion of an the diagnosis code. The approaches for external body part the obstetrical section are the same as the Packing: Putting material in a body part medical and surgical section. The device Traction: Exerting a pulling force on an exter- nal body part in a distal direction character has the same definition as the medical and surgical section and is used The body regions for the placement sec- for devices such as fetal monitoring elec- tion are either external body regions (e.g., trodes. The qualifier character is specific upper leg) or natural orifices. Since all to the root operation; it is used to specify placement procedures are performed on the type of delivery (e.g., low forceps, high an external body region or within an orifice forceps, etc.), the type of C-section (e.g., the approach is always none. The device classical, low cervical, etc.) or the type of fluid taken out during a drainage (e.g., character is always specified and indicates amniotic fluid, fetal blood, etc.). the material or device used in the place- ment procedure (e.g., cast, splint, ban- Placement Procedures dage, etc.). Except for casts for fractures The seven characters for the placement and dislocations, devices in the placement section have the following meaning: section are off the shelf and do not require any extensive design, fabrication or fitting. 12 3 4567 The placement of devices that require extensive design, fabrication or fitting are Section Root Operation Approach Qualifier coded in the rehabilitation section. The Anatomical Regions Body Region/ Device qualifier character is not used in the place- /Orifices Orifice ment section. Placement procedures, generally, refer to putting a device in or on a body region Administration for the purpose of protection, immobiliza- tion, stretching, compression or packing. A The seven characters for the administra- placement procedure always has a device tion section have the following meaning:

12 3M HIS Research Report 4-98 introduce contrast directly into the heart 12 3 4567 for angiography, then the procedure would

Section Root Operation Approach Qualifier be coded as a percutaneous intraluminal introduction of contrast into the heart. Physiological Systems Body/System Substance & Anatomical Regions Region The body systems/regions for arteries and veins are peripheral artery, central artery, peripheral vein and central vein. Administration procedures refer to the The peripheral artery or vein is used when putting in or on a therapeutic, prophylactic, a substance is introduced locally into an protective, diagnostic, nutritional or physi- artery or vein. For example, chemotherapy ological substance. Administration proce- would be the introduction of an antineo- dures have the first character specifying plastic substance into a peripheral artery the section designated with the number or vein by a percutaneous intraluminal “3”. For the administration section the approach. In general, the substance intro- body system has only two values indicat- duced into a peripheral artery or vein has ing physiological system and anatomical a systemic effect and not a local effect. region or circulatory system. The circula- tory body system is used for transfusion The central artery or vein is used when procedures. There are three root opera- the site within the artery or vein where the tions for the administration section. substance is introduced is distant from the

Introduction: Putting in or on a therapeutic, diagnostic, point of entry of the instrumentation into nutritional, physiological or prophylactic the artery or vein. The introduction of a substance except blood or blood substance using a catheter directly at the products site of a clot within an artery or vein would Irrigation: Putting in or on and retrieving a liquid be coded as an introduction of a throm- substance bolytic substance into a central artery or Transfusion: Putting in blood or blood products vein by a percutaneous intraluminal approach. In general, the substance intro- The fourth character specifies the body duced into a central artery or vein has a system/region which is the site where the local effect. administration occurs and not the site The sixth character specifies the sub- where the substance administered has an stance being introduced. There are broad effect. The sites include skin and mucous categories of substances, such as anes- membrane, subcutaneous tissue and thetics, contrast, or dialysate, plus blood muscle which are used to differentiate products specified in Character 6. intradermal, subcutaneous and intramus- cular injections. Character 5 specifies the Character 7 is a qualifier and is used to approach and has the same meaning as in indicate whether the introduction is single the medical and surgical section. The or continuous. Continuous introductions approach for intradermal, subcutaneous are used to specify that the introduction of and intramuscular introductions (i.e., injec- the substance required more than 15 min- tions) would be percutaneous. If a catheter utes. A standard IV would be a continuous is used to introduce a substance into an introduction of an electrolytic and water internal site within the circulatory system, balance substance into a peripheral vein then the approach would be percutaneous by a percutaneous intraluminal approach. intraluminal. Thus, if a catheter is used to For the circulatory body system, the quali-

3M HIS Research Report 4-98 13 fiers autologous and nonautologous are is the qualifier which is unique for each used to describe the substance adminis- procedure. An EKG would be the mea- tered. surement of cardiac electrical activity while an EEG would be the measurement of Measurement and Monitoring electrical activity of the central nervous system. A cardiac catheterization per- The characters for the measuring and formed to measure the pressure in the monitoring section have the following heart would be coded as the measure- meaning: ment of cardiac pressure by a percutane-

12 3 4567 ous intraluminal approach.

Section Root Operation Approach Qualifier Osteopathic

Physiological Systems Body System Function The seven characters for the osteo- pathic section have the following meaning: Measurement and monitoring proce- dures refer to the determination of the 12 3 4567 level of a physiological or physical func- Section Root Operation Approach Qualifier tion. If the equipment used to perform the measurement or monitoring is a device Anatomical Regions Body Region Method that is inserted and left in, then the inser- tion of the device is coded as a separate Osteopathic procedures have the first procedure. Measurement and monitoring character specifying the section desig- procedures have the first character speci- nated with the number “8”. For the osteo- fying the section designated with the num- pathic section, the body system character ber 4. For the measurement and has only one value, anatomical regions. monitoring section, the physiological sys- There is only one root operation in the tem has only one value. There are two osteopathic section. root operations in the measurement and monitoring section which are defined as: Treatment: Manual treatment to eliminate or alleviate somatic dysfunction and related disorders Measurement: Determining the level of a physiological or physical function at a point in time The fourth character specifies the body Monitoring: Determining the level of a physiological region on which the osteopathic manipula- or physical function repetitively over a tion is performed. The approach for osteo- period of time pathic manipulations is always none. The sixth character is the method which speci- The fourth character specifies the spe- fies the means by which the manipulation cific body system which is being measured is accomplished. The seventh character is or monitored. The fifth character specifies not used in the osteopathic section and the approach which has the same mean- always has the value none. ing as the medical and surgical section. The sixth character specifies the precise Extracorporeal Assistance and physiological or physical function being Performance measured or monitored. Examples of physiological or physical functions would The seven characters for the extracor- be conductivity, metabolism, pulse, tem- poreal assistance and performance sec- perature or volume. The seventh character tion have the following meaning:

14 3M HIS Research Report 4-98 12 3 4567 12 3 4567

Section Root Operation Duration Qualifier Section Root Operation Duration Qualifier

Physiological Systems Body System Function Physiological Systems Body System Qualifier In an extracorporeal assistance and per- In an extracorporeal therapy, equipment formance procedure, equipment external external to the body is used for a thera- to the body is used to assist or perform a peutic purpose that does not involve the physiological function. Extracorporeal assistance or performance of physiological assistance and performance procedures function. Extracorporeal therapies have have the first character specifying the sec- the first character specifying the section tion designated with the letter “B”. For the designated with the letter “C”. For the extracorporeal assistance and perfor- extracorporeal therapy section, the physio- mance section, the physiological system logical system has only one value. There has only one value. There are three root are six root operations in the extracorpo- operations in the extracorporeal assis- real therapy section. tance and performance section. Decompression: Extracorporeal elimination of undissolved gas from body fluids Assistance: Taking over a portion of a physiological function by extracorporeal means Hyperthermia: Extracorporeal raising of body temperature Performance: Completely taking over a physiological function by extracorporeal means Hypothermia: Extracorporeal lowering of body temperature Restoration: Returning, or attempting to return, a physiological function to its natural state Pheresis: Extracorporeal separation of by extracorporeal means blood products Phototherapy: Extracorporeal treatment by light The fourth character specifies the body rays system (e.g., cardiac, respiratory, etc.) for Ultraviolet Light Extracorporeal treatment by which extracorporeal assistance or perfor- Therapy: ultraviolet light mance is being used. The fifth character specifies the duration of the extracorporeal The fourth character specifies the body assistance or performance (i.e., single, system on which the extracorporeal ther- intermittent or continuous). For respiratory apy is performed (e.g., skin, circulatory, ventilation assistance or performance, the etc.). The fifth character specifies the range of hours is specified (<24 hours, 24- duration of the extracorporeal therapy 96 hours or >96 hours). The sixth charac- (e.g., single or intermittent). The sixth ter specifies the physiological function character is not used for extracorporeal being assisted or performed (e.g., oxygen- therapies and always has the value none. ation, ventilation, etc.). The seventh char- The seventh character is a qualifier which acter is a qualifier which specifies the type is only used to specify the components of of equipment used in the extracorporeal the circulatory system on which pheresis assistance or performance. is performed.

Extracorporeal Therapies Imaging Procedures The seven characters for the extracor- poreal therapies section have the following The seven characters for imaging proce- meaning: dures have the following meaning:

3M HIS Research Report 4-98 15 ther detail about the contrast material such 12 3 4567 as specifying the route of administration

Section Root Type Contrast Qualifier (e.g., IV, direct, via colostomy) or contains a qualifier specific to the root type of imag- Body System Body Part Contrast/Qualifier ing procedure. For example, for plain radi- ography procedures without contrast, The section for imaging procedures is character 6 indicates if the procedure was indicated by the number “5” in the first done at the bedside (portable). character. Imaging procedures include plain film, Fluoroscopy, CT, MRI, and Ultra- The seventh character is a qualifier that sound. Nuclear medicine procedures has a unique meaning for individual imag- including PET, uptakes and scans are in ing procedures. (e.g., Cine evaluation, the nuclear medicine section and thera- plain film subtraction, etc.) peutic radiology is in the radiation oncol- Contrast (character 5), contrast/qualifier ogy section. (character 6) and qualifier (character 7) The second character is the body sys- are not applicable to all imaging proce- tem and the fourth character is the body dures. part. The third character is the root type of imaging procedure (e.g, MRI, Ultrasound, Nuclear Medicine etc.). Table 7 contains the list of all root types for the imaging section with a defini- The seven characters for the nuclear tion of each root type. The fifth character medicine section have the following specifies the type of contrast material meaning: used in the imaging procedure (e.g., high or low osmolar). When the concentration 12 3 4567 of the contrast is not relevant (e.g., air) or for MRIs (e.g., Gadoteridol) the specific Section Type Radionuclide Qualifier contrast is specified. An “Identification Not Requested” option is allowed for character Body System Body Part Radiopharmaceutical 5 in the imaging section to be used in hos- Nuclear medicine is the introduction of pitals and other institutions where detailed radioactive material into the body in order information about contrast material is not to create an image, to diagnose and treat requested by the payor. pathologic conditions and to assess meta- The sixth character provides either fur- bolic functions. The nuclear medicine sec-

Plain Radiography Planar display of an image developed from the capture of external ionizing radiation on photographic or photoconductive plate.

Fluoroscopy Single plane or bi-plane real time display of an image developed from the capture of external ionizing radiation on fluorescent screen. The image may also be stored by either digital or analog means.

Computerized Tomogra- Computer-reformatted digital display of multiplanar images developed from the capture phy (CT Scan) of multiple exposures of external ionizing radiation.

Magnetic Resonance Computer reformatted digital display of multiplanar images developed from the capture Imaging (MRI) of radio frequency signals emitted by nuclei in a body site excited within a magnetic field.

Ultrasonography Real time display of images of anatomy or flow information developed from the capture of reflected and attenuated high frequency sound waves.

Table 7: Imaging Procedure Definitions

16 3M HIS Research Report 4-98 tion does not include the introduction of ter 5 specifies the radionuclide which is encapsulated radioactive material for the the source of the radiation and character 6 treatment of oncologic disease which is specifies the radiopharmaceutical agent. included in the radiation oncology section. As with devices in the medical and surgi- Nuclear medicine procedures have the cal section, a “not elsewhere classified” first character specifying the section desig- (NEC) option is included in the nuclear nated by the number “6”. The second medicine section to be used for newly character represents the body system on approved radiopharmaceuticals until they which the nuclear medicine procedure is can be explicitly added to the coding sys- performed. The third character indicates tem. An “Identification Not Requested” the type of nuclear medicine procedure option is allowed for characters 5 and 6 in (e.g., planar imaging or non-imaging the nuclear medicine section to be used in uptake). Table 8 contains the list of the hospitals and other institutions where types of nuclear medicine procedures with reporting of the radiopharmaceutical is not a definition of each type. requested by the payor. The fourth character indicates the body The seventh character is a qualifier and part or body region being studied. provides further details on the specific Regional (e.g., lower extremity veins) nuclear medicine procedure performed. and combination (e.g., liver and spleen) For example, the qualifiers used with body parts are commonly used in this sec- tomographic imaging of the heart include tion. rest, stress and wall motion. The fifth and sixth characters together If more than one introduction of radiop- specify the radiopharmaceutical used in harmaceutical is carried out then more the nuclear medicine procedure. Charac- than one code is used to describe a single

Planar Imaging Introduction of radioactive materials into the body for single plane display of images developed from the capture of radioactive emissions.

Tomographic (Tomo) Imaging Introduction of radioactive materials into the body for three dimensional display of images developed from the capture of radioactive emissions.

Positron Emission Tomo- Introduction of radioactive materials into the body for three dimensional display of graphic (PET) Imaging images developed from the simultaneous capture, 180 degrees apart, of radioac- tive emissions.

Nonimaging Uptake Introduction of radioactive materials into the body for measurements of organ function, from the detection of radioactive emissions.

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, alterna- tively, measurement of absorption of radioactive emissions from an external source.

Nonimaging Assay Introduction of radioactive materials into the body for the study of body fluids and blood elements, by the detection of radioactive emissions.

Systemic Therapy Introduction of unsealed radioactive materials into the body for treatment.

Table 8: Nuclear Medicine Procedure Definitions

3M HIS Research Report 4-98 17 nuclear medicine procedure. For example, the isotopes introduced into the body. a thallium scan of the heart during stress Ports are the number of beams directed at and at rest will have both a code for the the body part which is receiving the radia- stress study and a second code for a rest tion. Character 6 specifies the equipment study. When the procedure has two imag- used during a radiation oncology proce- ing sessions performed at different times, dure. The equipment includes external but not an additional administration of a protective devices which may be prefabri- radiopharmaceutical, the two imaging pro- cated or custom designed and constructed cedures are noted in the qualifier column. specifically for individual patients, implant For example, a stress with redistribution devices and other devices which are an thallium study has a qualifier to indicate integral part of the radiation oncology pro- the two separate imaging sessions. cedure (e.g., Gamma Knife). Character 7 represents a qualifier to the radiation Occasionally two radiopharmaceuticals oncology procedure. For radiation oncol- are used for a nuclear medicine proce- ogy treatments and simulations, character dure, and imaging is done simultaneously. 7 specifies the risk structures that are Two distinct codes are used, because two taken into account as part of the interven- radiopharmaceutical introductions have tion (e.g., eye, brain stem, spinal cord). been done. The risk structures are body parts that may be exposed to radiation and must be Radiation Oncology taken into account during the radiation oncology procedure. The seven characters for radiation oncology procedures have the following For medical physics procedures, the meaning: qualifier identifies the specific medical physics activity performed (e.g., dosime- 12 3 4567 try, irregular field calculation.

Section Modality Ports/Isotopes Qualifier/ An “Identification Not Requested” option Risk Structure is allowed for characters 5,6 and 7 in the Body System Treatment Site Device radiation oncology section and is used in The section for radiation oncology is hospitals and other institutions where indicated by the number “7” in the first reporting this level of detail is not character. The radiation oncology section requested by the payor. includes all radiation oncology proce- dures, including all treatment simulations and medical physics treatment support Rehabilitation and Diagnostic procedures performed as part of radiation Audiology oncology. The second character is the body system (e.g., Central Nervous Sys- The seven characters for the rehabilita- tem, Musculoskeletal) which is being irra- tion and diagnostic audiology section have diated. The third character specifies the the following meaning: modality or type of radiation which is being 12 3 used (e.g., photons, electrons). The fourth 4567 character specifies the body part that is Section Equipment the target of the radiation therapy. Charac- Test/Method ter 5 provides a count of the ports used or Type Body Part/System Qualifier

18 3M HIS Research Report 4-98 Rehabilitation procedures include physi- Chiropractic cal therapy, occupational therapy and speech-language pathology. Osteopathic The seven characters for the chiropractic procedures and chiropractic procedures section have the following meaning: are in separate sections. Rehabilitation 12 3 4567 and diagnostic audiology procedures have the first character specified with the num- Section Root Operation Approach Qualifier ber “9”. The type of procedure is specified in the second character. There are 4 differ- Anatomical Regions Body Region Method ent types of rehabilitation and diagnostic Chiropractic procedures have the first audiology procedures which are defined character specifying the section desig- as follows: nated with the letter “G”. For the chiroprac- Treatment: Use of specific activities or methods to tic section, the body system has only one develop, improve and/or restore the per- value. There is only one root operation in formance of necessary functions, com- the chiropractic section. pensate for dysfunction and/or minimize debilitation. Treatment: Manual treatment of the musculoskeletal Assessment: Includes a determination of the patient’s system to restore normal neurophysiologi- diagnosis when appropriate, need for cal function treatment, planning for treatment, peri- odic assessment and documentation The fourth character specifies the body related to these activities. site on which the chiropractic manipulation Fitting(s): Design, fabrication, modification, selec- is performed. The approach for chiroprac- tion and/or application of splint, orthosis, prosthesis, hearing aids and/or other tic manipulation is always none. The sixth rehabilitation device. character is the method which specifies Caregiver Educating caregiver with the skills and the means by which the manipulation is Training: knowledge used to interact with and accomplished. The seventh character is assist the patient. not used in the chiropractic section and The root operation treatment includes always has the value none. training as well as activities which restore function. The third and fourth characters Mental Health specify the exact test or method employed. For example, therapy to improve the range The seven characters for the mental of motion as well as training for bathing health section have the following meaning: techniques are two different types of treat- 12 3 4567 ment. The fifth character is the body part or system for which the procedure is being Section Type Expansion Qualifier Qualifier performed. Character 6 specifies the type of equipment used. Specific types of Type Qualifier Qualifier equipment are not specified. Rather, broad The mental health section provides categories of equipment are specified codes to describe the full range of ser- (e.g., aerobic endurance and conditioning vices provided by psychiatrists and other equipment, assistive/adaptive/supportive mental health professionals. The first char- devices, etc.) The seventh character is a acter for Mental Health procedures is “F”. qualifier and is only used for certain test/ The second character specifies the type of methods to specify whether the test/ procedure, such as crisis intervention, or method is group or individual. counseling. The third character is for pro-

3M HIS Research Report 4-98 19 cedure type expansion (e.g., to indicate that counseling was educational or voca- 12 3 4567 tional). The fourth character is a qualifier. Section Root Operation Approach Qualifier Characters 5,6 and 7 are never used and always have the value of none. Body System Body Region Method The miscellaneous section includes acu- Laboratory Procedures puncture, therapeutic massage and yoga therapy. The first character for miscella- The seven characters for the laboratory neous section procedures is “H”. The one section have the following meaning: value for body system is “anatomical region”. The miscellaneous section has 12 3 4567 only one root operation which is defined as follows: Section Analyte Specimen Source Other Therapies: Methodologies which attempt to remedi- ate or cure a disorder or disease. Analyte Method Class There is only one body region indicating Laboratory procedure codes are identi- the whole body. There is no approach, so fied by the letter “D” in the first character. the approach is always none. Character 6 designates the method (i.e., Acupuncture, The second character, the analyte class, Therapeutic Massage or Yoga Therapy). is a categorization of the major classes of There are no qualifiers, so none is always tests that are performed. There are six assigned to the seventh character. major classes and two extensions, in the laboratory section: Blood Bank, Hematol- Modifications to ICD-10-PCS ogy, Chemistry and Other Chemistry, Microbiology and Other Microbiology, Toxi- Throughout the development of ICD-10- cology and Pathology. PCS, extensive input from a wide range of organizations was obtained. A Technical The third and fourth characters specify Advisory Panel which included represen- the analyte, (i.e., the material being identi- tatives from the American Health Informa- fied or measured for each analyte class) tion Management Association, American (e.g., calcium, hematocrit). The fifth and Hospital Association and the American sixth characters identify the specimen if Medical Association provided review and applicable (e.g., cerebral spinal fluid). comment throughout the development of ICD-10-PCS. Character seven is the method used in the analysis (e.g., stain, culture). It is not The initial draft of ICD-10-PCS was always necessary to specify the method to widely disseminated. Both a paper and be used in a laboratory test. When a spe- computerized version of the system were cific method is not requested, standard made available. Copies of ICD-10-PCS method is used in character seven. were distributed to all major physician spe- cialty societies. HCFA made ICD-10-PCS available on its web site. Miscellaneous As a result of feedback from the exten- The seven characters for the miscella- sive review of ICD-10-PCS, the system neous section have the following meaning: was modified from its initial version to

20 3M HIS Research Report 4-98 reflect the suggestions from the reviewers. In the Medical and Surgical section, the The most frequent issue identified by NOS issue primarily relates to the root reviews was missing tabular entries, (i.e., operation, body part and approach charac- procedures were identified for which there ters. The operation repair is an operation was no corresponding tabular entry). Miss- of exclusion. Most of the other 29 root ing tabular entries most often related to operations constitute some type of repair. the need to allow additional approaches However, if the objective of the procedure for a specific procedure (e.g., a wide range meets the definition of one of the other of procedures that previously could only root operations then repair is not coded. be performed by an open approach can Repair is only coded when none of the now be performed by a percutaneous or other operations apply. In essence, repair percutaneous endoscopic approach). Sev- is the NOS option for the root operation eral additional root operations were character. The ICD-10-PCS coding defined in the medical and surgical section instructions were modified to indicate that (e.g., fusion). The approaches were sim- if the root operation can not be determined plified. Originally, there were 17 different from the documentation and the neces- approaches. The approaches that speci- sary information could not be obtained fied that the access location was the lining from the physician, then the root opera- of an orifice or was within the orifice itself tions repair should be coded. were eliminated. These approaches did In order to address the issue of insuffi- not constitute a critical distinction in cient anatomic specificity in the medical describing the procedure performed. record, the use of generic body parts was These approaches were incorporated into expanded. If the precise body part was not the other approaches by modifying the specified, then the option of coding a definition of some of the other generic body part was added. For exam- approaches. These changes reduced the ple, originally, for excision of the liver the number of approaches to 13. Biopsy is not precise part of the liver excised was a root operation since it is usually a form of required (i.e., right lobe, left lobe or cau- an excision. Many reviewers suggested date lobe). The generic body part “liver” that it was important to distinguish biop- was added as an option. Thus, if the docu- sies from therapeutic excisions. Therefore, mentation in the medical record does not a qualifier specifying that the excision was indicate the precise part of the liver and diagnostic was added. the specification of the precise body part of the liver could not be obtained from the One of the most frequent issues raised physician, then the coder has the option of concerning ICD-10-PCS was the issue of simply coding the body part as liver. This NOS codes. The concern was that suffi- in essence, provides the user with a “liver cient specificity of documentation may not NOS” option. The coder will still need to be present in the medical record to sup- identify the broad anatomic regions but will port the detail required by ICD-10-PCS. have a coding option when the full ana- Originally, ICD-10-PCS did not provide for tomic detail is not available in the medical NOS codes. As a result of these concerns, record and the necessary information modifications were made to ICD-10-PCS could not be obtained from the physician. to address this issue. Since ICD-10-PCS is a multi-axial system, the NOS issue was There are four broad approach types: addressed separately for each character. open, percutaneous, transorifice and

3M HIS Research Report 4-98 21 none. The ICD-10-PCS coding instruc- Table 9. tions were modified to indicate that if the The modifications made to ICD-10-PCS full detail on the type of approach can not to address the NOS issue strike a balance be determined, then the most basic open, between a precise description of the pro- percutaneous or transorifice approach cedure and the realities of the current should be coded. Minimally, the coder will state of medical records documentation. still need to be able to specify whether the approach was open, percutaneous, tran- sorifice or none. This distinction is so fun- Number of Codes in ICD-10-PCS damental to the description of the procedure that any less specificity relative Table 10 summarizes the number of to the approach would not be appropriate. codes by section in the final draft of ICD- 10-PCS. The number in parethesis for the While the NOS issue primarily related to imaging, nuclear medicine and radiation the medical and surgical section, there oncology sections specify the number of were also NOS related issues in some of additional codes that would be present if the other sections of ICD-10-PCS. The the full detail associated with the Identifi- imaging, nuclear medicine and radiation cation Not Requested characters in Table oncology sections of ICD-10-PCS allow 9 were included. the reporting of detail relating to the proce- dure that may not be readily available in Number of the hospital medical record. Further, in Section Codes these sections the level of detail allowed Medical and Surgical 176,367 by ICD-10-PCS, while important for inter- Obstetrics 322 nal management, may not be required by Placement 831 payors. For the characters in these sec- Administration 1,228 tions where the full detail of ICD-10-PCS Measurement and Monitoring 224 may not be required an “Identification Not Imaging 9,433 (13,141) Requested” option is provided. The sec- Nuclear Medicine 365 (1,011) tions and characters for which an Identifi- Radiation Oncology 1,225 (308,015) cation Not Requested Option is provided Osteopathic 100 are summarized in Table 9. Rehabilitation and Diagnostic 1,705 Audiology Section Character Extracorporeal Assistance and 28 Performance Imaging Character 5 - Contrast Extracorporeal Therapies 20 Nuclear Medicine Character 5 - Radionuclide Laboratory 2,681 Character 6 - Radiopharmaceutical Mental Health 283 Radiation Oncology Character 5 - Ports/Isotopes Character 6 - Device Chiropractic 100 Character 7 - Risk structure Miscellaneous 3 Table 9: Sections and characters for which an Total 194,915 Identification Not Requested option is provided Table 10: Number of ICD-10-PCS codes by section

There are a total of 197,769 codes in The Identification Not Requested option ICD-10-PCS which represents a substan- allows the procedure to be coded exclud- tial increase in the number of codes rela- ing the detail specified in the characters in tive to ICD-9-CM procedure codes. The

22 3M HIS Research Report 4-98 grid structure of ICD-10-PCS permits the and a separate one-day session was held specification of a large number of codes for the remaining sections (nuclear medi- on a single page in the Tabular division. cine, radiation oncology osteopathic, etc.) The combined Tabular and Index divisions The CDACs then spent several weeks of ICD-10-PCS are 1,087 pages which is coding with ICD-10-PCS to gain experi- approximately half the size of the Tabular ence. Conference calls were held to and Index in the ICD-10 diagnosis coding answer questions prior to the start of the manual from the World Health Organiza- formal testing. tion. In the first phase of the test, a sample of 5000 medical records (2500 per CDAC) Testing of ICD-10-PCS was selected, identifying cases with a wide distribution of ICD-9-CM procedure As an informal test in October 1996, codes. The CDACs coded the cases using seventy health information professionals ICD-10-PCS and noted any questions or were trained in ICD-10-PCS. After the concerns. These questions and other training, they coded a sample of records issues were forwarded to project staff, from their institutions using ICD-10-PCS which then responded on an ongoing and reported suggestions and problems to basis. As a result of this interaction, a list the ICD-10-PCS project staff. of revisions to the final draft was made. HCFA conducted a formal test of ICD-10- This included terms that needed clarifica- PCS in order to determine if it would be a tion and omissions in the tabular list or practical replacement for the current ICD- index sections. In addition, areas where 9-CM procedures. HCFA used two con- the training manual could be improved tractors to evaluate ICD-10-PCS. The con- were identified. tractors were the two Clinical Data In the second phase of the test, a subset Abstraction Centers (CDACs): DynKePRO of 100 medical records was recoded in York, PA, and FMAS in Columbia, MD. blindly using both ICD-9-CM and ICD-10- As part of a contract awarded in 1994, PCS. The reviewers coded the initial 50 the primary task of the CDACs has been records first with ICD-9-CM, then with to collect clinical data from about 1.5 mil- ICD-10-PCS. For the last 50 records, they lion medical records over five years. The reversed the process and began with ICD- primary end product of the CDAC con- 10-PCS. The systems were compared on tracts was the development of accurate issues such as ease of use, time needed and reliable clinical data in quantities suffi- to identify codes, number of codes cient to support the analytical efforts of the required, problems identifying codes, PROs as they carry out the Health Care strengths and weaknesses of each sys- Quality Improvement Program. Since the tem, and any other issues identified by the CDACs had a ready supply of current coding personnel. medical records and extensive experience After an initial learning curve, the CDAC in reviewing, abstracting and coding medi- coders were able to use ICD-10-PCS eas- cal records, they were selected to test ily, with a few challenges. Because of the ICD-10-PCS. added detail in ICD-10-PCS, it was occa- Using the ICD-10-PCS training manual, sionally necessary for the coders to utilize the CDACs were trained for two days on a medical dictionary or an anatomy text- the medical/surgical part of the system, book. The coders required a greater

3M HIS Research Report 4-98 23 understanding of anatomy and surgical in greater detail about the nature of the terms to use ICD-10-PCS than is required procedure and was therefore worthwhile. It for ICD-9-CM. As a result a greater was suggested that once coders became amount of training time will be necessary familiar with the greater detail and preci- for ICD-10-PCS than is currently required sion of ICD-10-PCS, the result would be for ICD-9-CM. Although the initial ICD-10- improved accuracy and efficiency of cod- PCS training manual was very useful, the ing. CDACS felt that it needed to be strength- Both CDACs pointed out that once the ened with additional examples before any coders were familiar with ICD-10-PCS, national training takes place. It was also they rarely used the index. The ICD-10- suggested by the CDACs that the addition PCS system was found to be so well orga- of diagrams of the body systems would be nized and so well structured that coders useful in the training manual. could quickly find the correct section of the Once the CDAC coders became profi- tabular list. The index was used more cient in ICD-10-PCS, they were able to often when the coder was just learning the suggest a number of improvements, such definitions of the root procedures and the as additional index entries and revisions to other basic terms used in ICD-10-PCS. the body site and approach characters. However, once coders understood ICD- These suggestions were included in the 10-PCS, they found it easy to code from final draft of ICD-10-PCS. The testing the tabular section. pointed out the ease with which ICD-10- Both CDACs found ICD-10-PCS to be PCS can be updated and expanded when an improvement over ICD-9-CM as it pro- issues are identified. Another area of con- vided greater specificity in coding for use cern was correct code assignment for in research, statistical analysis, and records that did not provide enough docu- administrative areas. A major strength of mentation of a specific site or the type of the system was its detailed structure, procedure or when the coders did not which allowed users to recognize and have enough knowledge of anatomy to report more precisely the procedures that select a precise code. The concerns were performed. resulted in the modification of the ICD-10- PCS coding rules to address this issue. Comparison of ICD-10-PCS and A side-by-side comparison of ICD-10- ICD-9-CM PCS and ICD-9-CM was performed when the coders became proficient with the use In 1993, the National Committee on Vital of the new system. One CDAC reported & Health Statistics (NCVHS) issued a that the staff did not detect a significant report concerning recommendations for a time difference in using ICD-10-PCS as single procedure classification system. As compared to ICD-9-CM. The other CDAC part of this report, NCVHS identified the found that ICD-10-PCS coding took some- essential characteristics that a procedure what longer. ICD-10-PCS sometimes classification system should possess. The required a greater number of codes than characteristics listed in Table 11 are taken ICD-9-CM. This was due in part to the use directly from the NCVHS report and sum- in ICD-9-CM of more combination codes marizes the essential characteristics of a than in ICD-10-PCS. However, it was felt procedure coding system. Included in that the precision of ICD-10-PCS resulted Table 11 is a comparison of ICD-9-CM and

24 3M HIS Research Report 4-98 one code to only ICD-10-PCS ssigned a The ability to aggregate across all essential compo- ofnents a procedure is provided All codes have a unique definition Extensive flexibility New procedures and technologies are easily incorpo- rated.code Unlimitedavailable numbers empty Update process needsbe to established. ICD-10- If PCS replaces ICD-9-CM, CoordinationMainte- and nance Committee would be responsible for update process Code expansionsdisruptdo systematic structure not LimitedNECandcategories.NEC use of NOS and NOS categories are specific to eachcode. All axis of proceduresbecan categorized somewhere. Proce- dure codesprecisely are definedwhen even NOS andare NEC optionsused typesAll of procedures are includedevalua-except tion and management procedures. Completedetail is providedtypes for all of procedures All settings and types of providers are covered except physician office services for evaluation and manage- ment. Complete detail is provided for all settings and types of providers Each procedure is ICD-9-CM The ability to aggregateprovidedby body system is but there is no ability to aggregate by other compo- ofnents a procedure docodesSome not have a unique definition becausehavethe codes been reused Minimal flexibility Newand procedures to technologies are difficult codeno numbers empty incorporate. Virtually Updatedannually throughCoordination and Mainte- nance Committee Code expansions are to difficult incorporate without disrupting systematic code structure andofuseExtensive NEC categories. NOS All pro- cedures can be categorizedBroad somewhere. NOS and NEC categories result in procedure codes which are ambiguouslydefined types of proceduresAll are included althoughthere is minimaloffor many types detail procedure settingsAlland of providers types are covered although thereminimal detail is for many settings andof providers types The same proceduredifferent when performed for diagnoses is sometimes assigned to multiple codes Comparison of ICD-9-CM and ICD-10-PCS Using the NCVHS Characteristics Table 11: NCVHS Characteristics code numbers) ” empty “ Hierarchical structure Ability to aggregate data from individual codes into larger categories codeEach has a unique definitionreusednot forever - Expandibility Flexibilitynew toand procedures technologies ( Mechanism for periodic updating Code expansion must not disrupt systematic code structure Comprehensive Provides NOS and NEC categories so that all possible procedures can be classified somewhere proceduresIncludes all types of Applicability to all settingproviders and types of Non-Overlapping procedureEacha procedure)(or component is of assigned to only one code

3M HIS Research Report 4-98 25 in the code All terminology is precisely defined. All terminology is used constantly across all codes Full index. Index is computer generated so specificity of index is consistent across codes Codes are independent of who or where procedure is performed A specific characterspecifiesthe code in the body system effected specified in the used is charac- approach Technology ter of the code techniques/approachesThe used are specified in the approach character of the code andPhysiological pharmacological effect properties are specifiedwhento the procedure relevant characteristics/compositionTheof implants are spec- ifiedofcharacter the code in the device inconsistent across codes codes Codes are independent of who or whereprocedure performed is can be determined from code Body system affected number Limitedinconsistent and technology specification of used Limitedinconsistent and techniques/ specification of approaches used Limitedinconsistent and physiologi- specification of cal effect and pharmacological properties Limited an inconsistent specificationof characteris- tics/composition of implant No otherNodata elements includedin code other No data elements included in code ComparisonICD-9-CM of andICD-10-PCS Using the NCVHSCharacteristics (Continued) Table 11: NCVHS Characteristics ICD-9-CM ICD-10-PCS Adequate indexing and annotationfor all users Fullindexindex varies across but specificity of used Technology used Techniques/approaches or pharmacological propertiesPhysiological effect Characteristics/composition of implant Ease of Use Standardization of definitionsand terminology is standard No definitions provided. Terminology Neutrality Provider and Setting regardlessSame codeofor where who procedure is performed Multi-axial Body system(s) affected Procedures of to Classification Limited Should not includediagnostic information Diagnosticinformation some is includedcodes for diagnostic No information is included Other dataOther elements (such as age) shouldelse- be where in the record

26 3M HIS Research Report 4-98 ICD-10-PCS across each of the NCVHS the procedure performed. The specifica- characteristics. As the comparisons in tion of the procedures performed not only Table 11 indicate, ICD-10-PCS meets vir- affects payment but is integral to internal tually all the NCVHS characteristics while management systems, external perfor- ICD-9-CM fails to meet many of the mance comparisons and the assessment NCVHS characteristics. of quality of care. The detail and complete- ness of ICD-10-PCS is essential in today’s In addition to the NCVHS characteris- health care environment. tics, there are several other attributes of a procedure coding system that should be Communications with Physicians taken into consideration when comparing ICD-9-CM procedure codes often pro- systems. vide a relatively poor description of the Training Effort precise procedure performed. Thus, physi- cians reviewing or analyzing data coded in As the independent evaluation of ICD- ICD-9-CM can have difficulty developing 10-PCS demonstrated there a is learning clinical pathways, evaluating the coding curve associated with ICD-10-PCS. Since from a fraud and abuse perspective or per- the CDAC staff were trained ICD-9-CM forming research. The ICD-10-PCS codes coders, the independent evaluation did not provide a more clinically relevant descrip- include a formal comparison of the training tion of procedures that can be more time for ICD-10-PCS and ICD-9-CM. How- readily understood and used by physi- ever, because of the additional specificity cians. of ICD-10-PCS it is likely that the training time needed to achieve a minimum level of coding proficiency is greater with ICD-10- Conclusion PCS than with ICD-9-CM. While it may ICD-10-PCS has been developed as a take longer to reach a minimum level of replacement for Volume 3 of ICD-9- proficiency with ICD-10-PCS, it should CM.The system has evolved during its five take less time to become highly proficient year development based on extensive with ICD-10-PCS than with ICD-9-CM. input from many segments of the health Because ICD-9-CM lacks clear definitions care industry. The multi-axial structure of and many substantially different proce- the system combined with its detailed defi- dures are coded with the same code, the nition of all terminology will permit a pre- identification of the correct code requires cise specification of procedures for use in extensive knowledge of the contents of health services research, epidemiology, Coding Clinic and other coding guidelines. statistical analysis and administrative Becoming completely familiar with all the areas. It will also enhance the ability of conventions associated with ICD-9-CM health information coders to determine requires extensive effort and as a result, accurate procedure codes with minimal the process of becoming highly proficient effort. in ICD-9-CM can require a long learning curve. Completeness and Accuracy of Codes The CDACs concluded that procedures coded in ICD-10-PCS provided a much more complete and accurate description of

3M HIS Research Report 4-98 27 APPENDIX A Medical and Surgical Root Operation Definitions Alteration Definition: Modifying the natural anatomical structure of a body part without affecting the function of the body part Explanation: Principal purpose is to improve appearance Examples: Face lift Breast augmentation Bypass Definition: Altering the route of passage of the contents of a tubular body part Explanation: Rerouting contents around an area of a body part to another distal (down stream) area in the normal route; rerouting the contents to another different but similar route and body part; or to an abnormal route and another dissim- ilar body part. Examples: Gastrojejunal bypass Coronary artery bypass Change Definition: Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane Explanation: Requires no invasive intervention Example: Change a drainage tube Control Definition: Stopping or attempting to stop, postprocedural bleeding Explanation: Confined to postprocedural bleeding and limited to the Anatomical Regions, Upper Extremities and Lower Extremities body systems Examples: Control of postprostatectomy bleeding Control of postpneumonectomy bleeding Creation Definition: Making a new structure that does not physically take the place of a body part Explanation: Confined to sex change operations where genitalia are made Examples: Create an artificial vagina in a male Create an artificial penis in a female Destruction Definition: Eradicating all or a portion of a body part Explanation: The actual physical destruction of all or a portion of a body part by the direct use of energy, force or a destructive agent. There is no tissue taken out. Examples: Fulgurate a rectal polyp Crush a fallopian tube Detachment Definition: Cutting off all or a portion of an extremity Explanation: Pertains only to extremities. The body part determines the level of the detachment. All of the body parts distal to the detachment level are detached Examples: Shoulder disarticulation Below knee amputation Dilation Definition: Expanding the orifice or the lumen of a tubular body part Explanation: Stretching by pressure using intraluminal instrumentation Examples: Dilate the trachea Dilate the anal sphincter

28 3M HIS Research Report 4-98 Medical and Surgical Root Operation Definitions Division Definition: Separating, without taking out, a body part Explanation: Separating into two or more portions by sharp or blunt dissection Examples: Bisect an ovary Spinal cordotomy Divide a patent ductus Drainage Definition: Taking or letting out fluids and/or gases from a body part Explanation: The fluids or gases may be normal or abnormal Examples: I & D of an abscess Thoracentesis Excision Definition: Cutting out or off, without replacement, a portion of a body part Explanation: Involves the act of cutting with either a sharp instrument or other method such as a hot knife or laser. The qualifier “diagnostic” is used to identify exci- sions that are biopsies Examples: Partial nephrectomy Liver biopsy Pulmonary segmentectomy Extirpation Definition: Taking or cutting out solid matter from a body part Explanation: Taking out solid matter (which may or may not have been broken up) by cut- ting with either a sharp instrument or other method such as a hot knife or laser, by blunt dissection, by pulling, by stripping or by suctioning, with the intent not to take out any appreciable amount of the body part. The solid matter may be imbedded in the tissue of the body part or in the lumen of a tubular body part. Examples: Sequestrectomy Cholelithotomy Extraction Definition: Taking out or off all or a portion of a body part Explanation: The body part is not completely dissected free but is pulled or stripped by the use of force (e.g., manual, suction, etc.) from its location. The qualifier “diagnostic” is used to identify extractions that are biopsies. Examples: Tooth extraction Vein stripping Dermabrasion Fragmentation Definition: Breaking down solid matter in a body part Explanation: Physically breaking up solid matter which is not normally present in a body part such as stones and foreign bodies. The break up may be accomplished by direct physical force or shock waves applied directly or indirectly through intervening layers. The resulting debris is not taken out but is passed from the body or absorbed by the body. The solid matter may be in the lumen of a tubular body part or in a body cavity. Examples: Lithotripsy, urinary stones Lithotripsy, gallstones Fusion Definition: Joining together portions of an articular body part rendering the articular body part immobile Explanation: Confined to joints Examples: Spinal fusion Ankle arthrodesis

3M HIS Research Report 4-98 29 Medical and Surgical Root Operation Definitions Insertion Definition: Putting in a nonbiological appliance that monitors, assists, performs or pre- vents a physiological function, but does not physically take the place of a body part Examples: Implant a radioactive element Insert a diaphragmatic pacemaker Inspection Definition: Visually and/or manually exploring a body part Explanation: Looking at a body part directly or with an optical instrument or feeling the body part directly or through intervening body layers Examples: Diagnostic arthroscopy Exploratory laparotomy Map Definition: Locating the route of passage of electrical impulses and/or locating func- tional areas in a body part Explanation: Confined to the cardiac conduction mechanism and the central nervous system Examples: Map cardiac conduction pathways Locate cortical areas Occlusion Definition: Completely closing the orifice or lumen of a tubular body part Explanation: Can be accomplished intraluminally or extraluminally Examples: Ligate the vas deferens Fallopian tube ligation Reattachment Definition: Putting back in or on all or a portion of a body part Explanation: Pertains only to body parts or appendages that have been severed. May or may not involve the re-establishment of vascular and nervous supplies. Examples: Reattach penis Reattach a hand Replant parathyroids Release Definition: Freeing a body part Explanation: Eliminating abnormal compression or restraint by force or sharp or blunt dis- section. Some of the restraining tissue may be taken out but none of the body part itself is taken out. Examples: Lyse peritoneal adhesions Free median nerve Removal Definition: Taking out or off a device from a body part Explanation: May or may not involve invasive intervention Examples: Remove a drainage tube Remove a cardiac pacemaker Repair Definition: Restoring to the extent possible, a body part to its natural anatomical struc- ture Explanation: An operation of exclusion. Most of the other operations are some type of repair but if the objective of the procedure is one of the other operations then that operation is coded. If none of the other operations are performed to accomplish the repair then the operation “repair” is coded. Examples: Tracheoplasty Suture laceration Herniorrhaphy

30 3M HIS Research Report 4-98 Medical and Surgical Root Operation Definitions Replacement Definition: Putting in or on a biological or synthetic material that physically takes the place of all or a portion of a body part Explanation: The biological material may be living similar or dissimilar tissue from the same individual or non-living similar or dissimilar tissue from the same indi- vidual, another individual or animal. The body part replaced may have been previously taken out, previously replaced, or may be taken out concomi- tantly with the replacement. Examples: Replace external ear with synthetic prosthesis Total hip replacement Replacement of part of the aorta Free skin graft Pedicle skin graft Reposition Definition: Moving to its normal location or other suitable location all or a portion of a body part Explanation: The body part repositioned is aberrant, compromised or may have been detached. If attached, it may or may not be detached to accomplish the repositioning Examples: Reposition undescended testicle Reposition an aberrant kidney Resection Definition: Cutting out or off, without replacement, all of a body part Explanation: Involves the act of cutting with either a sharp instrument or other method such as a hot knife or laser Examples: Total gastrectomy Pneumonectomy Total nephrectomy Restriction Definition: Partially closing the orifice or lumen of a tubular body part Explanation: Can be accomplished intraluminally or extraluminally Examples: Fundoplication Cervical cerclage Revision Definition: Correcting a portion of a previously performed procedure Explanation: Redoing a portion of a previously performed procedure that has failed to function as intended. Revisions exclude the complete redo of the procedure and procedures to correct complications that do not require the redoing of a portion of the original procedure, such as the control of bleeding. Examples: Revise hip replacement Revise gastroenterostomy Transfer 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 is not detached from the body. Its vascular and nerve supply remain intact. The body part whose function is taken over may or may not be similar. Examples: Nerve transfer Tendon transfer Transplantation Definition: Putting in or on all or a portion of a living body part taken from another indi- vidual or animal to physically take the place and/or function of all or a por- tion of a similar body part Explanation: The native body part may or may not be taken out. The transplanted body part may either physically take the place of the native body part or simply take over all or a portion of its function. Examples: Lung transplant Kidney transplant

3M HIS Research Report 4-98 31 Tendon Tendon transfer Undescended testicle Heart transplant Lithotripsy, gallstones Lithotripsy, function of similar body partfunction of similar body Body part may or may not be detachedBody part may cally takes the place and/or function of all or a ofpartportion a body of the solid matter Appendix B Operations that take out or eliminate all or a portion of a body part: part: body a of a portion or all eliminate or out take that Operations Comparison of Medical and Surgical Root Operations Operations that involve putting in or on, putting back, or moving living body parts: Operations that take out or eliminate solid matter, fluids, or gases or fluids, from a body part: gases matter, solid that eliminate take out or Operations Operation Action Object Modification Example Transfer Move All or a portion of a body part Without taking out the body part; takes over ReattachmentRepositionon or in back Putting or All a portionparta body of Move Body part was detached All or a portion of a body part Reattachfinger Put in its normal or other suitable location. Transplantation Putting in or on All or a portion of a living body part from other individual or animal; physi- Taken ExcisionResectionExtractionDestruction Cuttingor off out or offout Cutting Detachmentofpart Portion a body off out or Taking Allofpart Eradicating a body Cutting off Allor a portionparta body of or All a portionparta body of Withoutreplacementof the body part All or a portion of an Withoutreplacement extremityof the body part Withoutreplacementof the body part Withoutreplacementof the body part extraction Without replacement of the extremity Toenail Sigmoid polypectomy Fulguraterectalpolyp nephrectomy Total Below the knee amputation DrainageExtirpationFragmentation or letting out Taking Breaking down bodyaand/or Fluid part from gases or cutting out Taking Solida body matter in part partthe bodyany taking of Without out Solid matter in a body partan abscess & D of I partthe bodyanytaking Without of out Without takingany out of the body part or any Sequestrectomy

32 3M HIS Research Report 4-98 Change a drainage tube ways. Locate cortical areas Gastrojejunal bypass insertion Pacemaker hip replacement Total mucous membrane None Cardiac conduction path- biological material or synthetic material which partof the bodytake the place not does part By applicationBy of pressure Dilatesphincter anal Physically takes the place of all or a portion of parta body None Fallopian tube ligation None Cervical cerclage Operations that always involve devices: Operationscanthatbe performed onlytubular on body parts: Identical or similar device Withoutcuttingor puncturing the skin or A body partA body impulses. Functional areas in a body part. None Diagnostic arthroscopy Contents of tubular body part May include use of living tissue, non living part tissue taken from same individual part part Operationsbody parts that only involve and regions:of examination Comparison of Medical and Surgical Root Operations and putting back ual exploration passage Operation Action Object Modification Example Map Locating Route of passage of electrical Dilation Expanding tubularlumen of a Orifice or body Replacement Putting in or on RemovalChangeliving material; synthetic or Biological off out or Taking off out or Taking Device Nonepacemaker cardiac Remove Inspectionman- and/or Visual Bypass Altering the route of Insertion Puttingin Non biological appliancenot Does physically place take theof body Occlusion Completely closingtubularlumen Orifice of a or body Restriction Partially closingtubularlumen Orifice of a or body

3M HIS Research Report 4-98 33 Lyse peritoneal adhesions Lyse Hernia repair tomy bleeding bleeding tomy Artificial vagina without taking out any of the body part May include use of living tissue, nonliving bio- logical material or synthetic material which ortake over the func-take the placenotdoes bodytion of the part Procedure failedto function as intended Revise hip replacement Withoutaffecting function bodya part of Face lift part Miscellaneous operations: its natural anatomicits natural structure procedure Postproceduralbleeding to anatomic Limited regions and extremities Control of postprostatec- body part Comparison of Medical and Surgical Root Operations ingstop to Operation Action Object Modification Example RepairRevision Restoring Correctingbodya the extent possible, part to To of Portion a previously performed DivisionFusion Release Separating Joiningtogether Freeingbody An articular part A body partpart A body Rendering body part immobile Without taking out any of the body part Spinal fusion Bisect ovary eliminating By restriction; compression or Alteration ModifyingControl Natural anatomicala structures of Stopping or attempt- Creation Makingstructure New not Does physically place take theof a body

34 3M HIS Research Report 4-98 CommonExploration Duct Open Colonoscopy with Polypectomy Arthroscopy Femoral Artery Embolectomy Percutaneous Gastroscopy Insert Endotracheal Tube Sigmoidoscopy Intraluminal Intraluminal Endoscopic Endoscopic Intraluminal Intraluminal Endoscopic Intraluminal Intraluminal Endoscopic

Route Approach Example APPENDIX C Type of Instrumentation Method Components of the Medical and Surgical Approach Definitions Access Location Skin or Mucous Membrane Mucous or Skin Open Membraneor Mucous Skin Open InstrumentalVisualization Without Intraluminal Open N/A N/A Open Hysterectomy Abdominal Skin or Mucous Membraneor Mucous Skin Open InstrumentalVisualization With or Mucous MembraneSkin Membraneor Mucous Skin Instrumental Instrumental Intraluminalor Mucous MembraneSkin Open Instrumental WithoutVisualization or Mucous MembraneSkin Visualization With N/A Instrumental WithoutVisualization Orifice N/A Intraluminal WithVisualization Orifice Percutaneous Percutaneous Intraluminal Percutaneous or Mucous MembraneSkin Percutaneous NeedleLiver Biopsy of N/A Instrumental Instrumental Without Visualization N/A Intraluminal With Visualization Transorifice Intraluminal Transorifice N/A None ClosedFracture Reduction © 3M 1998

3M HIS Research Report 4-98 35