Development of the ICD-10 Procedure Coding System (ICD-10-PCS) · 2018. 2. 16. · ICD-10-PCS was under devel-opment for over five years and the initial draft was formally tested

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-eases 10th Revision Procedure Classifica-tion System (ICD-10-PCS) has beendeveloped as a replacement for Volume 3of the International Classification of Dis-eases 9th Revision. The development ofICD-10-PCS was funded by the U.S.Health Care Financing Administration.ICD-10-PCS has a multi-axial seven char-acter alphanumerical code structure whichprovides a unique code for all substantiallydifferent procedures and which allows newprocedures to be easily incorporated asnew codes. ICD-10-PCS was under devel-opment for over five years and the initialdraft was formally tested and evaluated byan independent contractor. The final ver-sion of the ICD-10-PCS was released inthe Spring of 1998. The design, develop-ment and testing of ICD-10-PCS are dis-cussed.

_________________________________

The ICD-10-PCS is being developed with the support of the Health CareFinancing Administration, under contract Nos. 90-1138, 91-22300 and500-95-0005 to 3M Health Information Systems. Consultation in thedevelopment of ICD-10-PCS was provided by Donn G. Duncan, M.D.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-opment of the Health Care Financing Administration, DHHS, providedongoing review and evaluation during the development of the ICD-10-PCS: Patricia E. Brooks, Ann Bowling Fagan, Amy L. Gruber. A widerange of physician specialty societies, individual clinicians, health careprofessionals and researchers provided valuable input into the research.The Tabular List, Code Descriptions, and Index were computer gener-ated based on an expert system designed by: Yvette Wang, LaurenceGregg, Enes Elia, and David Gannon. Address correspondence andrequests for reprints to Richard F. Averill, M.S., Senior Director, ClinicalResearch Department, 3M Health Information Systems, 100 BarnesRoad, Wallingford, CT 06492. Robert L. Mullin, M.D., Barbara Steinbeck,ART, Norbert I. Goldfield, M.D., Thelma Grant, RRA, are with 3M HealthInformation Systems, 3M Health Care. The opinions expressed are solelythose of the authors and do not necessarily reflect the views or policypositions of 3M Health Information Systems or the Health Care FinancingAdministration.

Introduction

Volume 3 of the International Classifica-tion of Diseases 9th Revision ClinicalModification (ICD-9-CM) has been used inthe U.S. for the reporting of inpatient pro-cedures since 1979. The structure of Vol-ume 3 of ICD-9-CM has not allowed newprocedures associated with rapidly chang-ing technology to be effectively incorpo-rated as new codes. As a result, in 1992the U.S. Health Care Financing Adminis-tration (HCFA) funded a project to producea preliminary design for a replacement forVolume 3 of ICD-9-CM. After a review ofthe preliminary design, HCFA in 1995awarded 3M Health Information Systems athree year contract to complete the devel-opment of a replacement system. The newsystem is named ICD-10 Procedure Cod-ing System (ICD-10-PCS).

The development of ICD-10-PCS hasfour major objectives:

Completeness

There should be a unique code for allsubstantially different procedures. InVolume 3 of ICD-9-CM, procedures ondifferent body parts, with differentapproaches, or of different types aresometimes assigned to the same code.

Expandability

As new procedures are developed thestructure of ICD-10-PCS should allowthem to be easily incorporated as uniquecodes.

3M HIS Research Report 4-98 1

Multi-axialICD-10-PCS should have a multi-axial

structure with each code character havingthe same meaning within a specificprocedure section and across proceduresections to the extent possible.Standardized Terminology

ICD-10-PCS should include definitionsof the terminology used. While themeaning of specific words can vary incommon usage, ICD-10-PCS should notinclude multiple meanings for the sameterm and each term must be assigned aspecific meaning.

If these four objectives are accom-plished, then ICD-10-PCS should enhancethe ability of health information coders todetermine accurate codes with minimaleffort.

In the development of ICD-10-PCS,there were several general guidelines thatwere followed:

Diagnostic Information is Not Included inProcedure Description

When procedures are performed forspecific diseases or disorders, the diseaseor disorder is not specified. Thus, thereare no separate codes for procedures foraneurysms, cleft lip, strictures, neoplasms,hernias, etc. The diagnosis codes and notthe procedure codes contain the specificinformation regarding the nature of thedisease or disorder.Explicit Not Otherwise Specified (NOS)Options are Not Provided

ICD-9-CM will often provide a “nototherwise specified” option. Explicit NOSoptions are not provided in ICD-10-PCS. Aminimal level of specificity is alwaysrequired for each component of theprocedure. For each component of theprocedure there are ICD-10-PCS codingrules that specify how the procedureshould be coded when there is insufficient

information available in the medical recordto support the specificity required by ICD-10-PCS.Limited Use of Not Elsewhere Classified(NEC) Option

ICD-9-CM will often provide a “notelsewhere classified” option. All possiblecomponents of a procedure are specifiedin ICD-10-PCS, thus, in general, there isno need for a “not elsewhere classified”option. However, new devices arefrequently being developed and therefore,for devices, it is necessary to have a “notelsewhere classified” option that can beused until the new device can be explicitlyadded to the coding system. Likewise, anNEC option is included in the nuclearmedicine section that can be used fornewly approved radiopharmaceuticalsuntil they can be explicitly added to thecoding system.Level of Specificity

Based on the combinations of the sevenalphanumeric characters, all possibleprocedures were defined. Frequency ofoccurrence was not a consideration in thedevelopment of the system. A code wascreated for any procedure that could beperformed.

ICD-10-PCS has a seven characteralphanumeric code structure. Each char-acter has up to 34 different values. Theten digits 0-9 and the 24 letters A-H,J-Nand P-Z comprise each character. The let-ters O and I are not used in order to avoidconfusion with the digits 0 and 1.

Procedures are divided into sectionsthat relate to the general type of procedure(e.g., medical and surgical, imaging, etc.).The first character of the procedure codealways specifies the section. The sectionsare shown in Table 1.

The second through seventh charactershave a standard meaning within each sec-

2 3M HIS Research Report 4-98

tion but may have different meaningsacross sections.

In most sections, one of the charactersspecifies the precise type of procedurebeing performed (e.g., excision, resection,etc.), while the other characters specifyadditional information such as the bodypart on which the procedure is being per-formed. In the ICD-10-PCS the term “pro-cedure” is used to refer to the completespecification of the seven characters.

ICD-10-PCS Manual

In the ICD-10-PCS system, the ICD-10-PCS codes are described in three sepa-rate divisions.

Tabular ListingIndexList of Codes

The Index allows codes to be located byan alphabetic look up. The Index entry willrefer to a specific location in the TabularList. Reference to the Tabular List isalways necessary in order to obtain thecomplete code. The list of codes allows a

direct look up of each code and provides ashort description of each code.

Tabular List in ICD-10-PCS Manual

The Tabular List in ICD-10-PCS has avery different organization than ICD-9-CM.Each page in the Tabular List is composedof grids which specify the valid combina-tions of character values that comprise aparticular procedure code. Table 2 showsa portion of a page from the Tabular List.The upper portion of each grid contains adescription of the first two or three charac-ters of the procedure code. For example,for procedures in the medical and surgicalsection the first three characters are thename of the section, the body system andthe root operation being performed.

In ICD-10-PCS characters 027 wouldindicate that the grid refers to the medicaland surgical section (0) of the body sys-tem heart & great vessels (2) and a rootoperation of dilation (7). As shown in Table2 the root operation (i.e., dilation) is fol-lowed by its definition.

The lower portion of the grid specifies allthe valid combinations of characters fourthrough seven. The four columns in thegrid represent the last four characters andfor the medical and surgical section arelabeled Body Part, Approach, Device andQualifier, respectively. Each row in the griddefines the valid combinations of charac-ters four through seven. The Tabular Listcontains only combinations of charactersthat represent a valid procedure. Combi-nations of characters that do not constitutea valid procedure are not contained in theTabular List.

The grid in Table 3 generates 48 uniqueprocedure codes. For example, code02705DZ represents the procedure fordilation of one coronary artery using anintraluminal device by a percutaneousintraluminal approach (i.e., percutaneous

Sections

0 Medical and Surgical

1 Obstetrics

2 Placement

3 Administration

4 Measurement and Monitoring

5 Imaging

6 Nuclear Medicine

7 Radiation Oncology

8 Osteopathic

9 Rehabilitation and Diagnostic Audiology

B Extracorporeal Assistance and Performance

C Extracorporeal Therapies

D Laboratory

F Mental Health

G Chiropractic

H Miscellaneous

Table 1: Sections


transluminal coronary angioplasty withstent).

List of Codes

The actual codes that result from thefirst body part (i.e., one coronary artery) inthe grid for dilation of heart and great ves-sels are listed in Table 3. The 12 codeslisted in Table 3 are examples of entries inthe List of Codes. Each code has adescription that is complete and easy toread.

Index

The Index allows codes to be locatedbased on an alphabetic look up. Codescan be found in the index based on thetype of procedure being performed. Thus,the code for a percutaneous intraluminaldilation of the coronary arteries with an

intraluminal device can be found in theIndex under dilation, or any synonym ofdilation (e.g., angioplasty). Once thedesired term is located in the Index, theIndex specifies the first three or four char-acters of the code followed by three peri-ods (e.g., 0270...). Each entry in theTabular List refers to the first three charac-ters of the code (e.g., 027). Based on thefirst three characters of the code obtainedfrom the Index, the corresponding entry inthe Tabular List can be located. The Tabu-lar List is then used to obtain the completecode by specifying the possible combina-tions of the last four characters.

Medical and Surgical Procedures The seven characters for medical and sur-gical procedures have the following mean-ing:

0: Medical and Surgical2: Heart and Great Vessels7: Dilation: Expanding the orifice or the lumen of a tubular body part

Body PartCharacter 4

Approach Character 5

Device Character 6

Qualifier Character 7

0 Coronary Artery, One 1 Open Intraluminal DIntraluminal Device Z None

1 Coronary Arteries, Two 2 Open Intraluminal Endoscopic YDevice NEC

2 Coronary Arteries, Three 5 Percutaneous Intraluminal Z None

3 Coronary Arteries, Four or More

6 Percutaneous Intraluminal Endoscopic

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)

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)


SECTION

The medical and surgical section consti-tutes the vast majority of procedures thatwould normally be reported in an inpatientsetting. Medical and surgical procedureshave the first character specifying the sec-tion designated with the number “0”.

BODY SYSTEM

The second character indicates the gen-eral body system (e.g., gastrointestinal).The third character indicates the root oper-ation which specifies the objective of theprocedure (e.g., repair). The fourth char-acter indicates the specific part of the bodysystem on which the procedure was per-formed (e.g., duodenum). The fifth charac-ter indicates the approach used to reachthe site of the procedure (e.g., open). Thesixth character indicates whether anydevice was used in the procedure (e.g.,synthetic substitute). The seventh charac-ter is a qualifier that has a unique meaningfor individual procedures. For example,the qualifier can be used to identify thesecond site involved in a bypass. Charac-ters 1-4 must always be assigned a pre-cise value. The approach (character 5),the device (character 6) and the qualifier(character 7) are not applicable to all pro-cedures. The letter Z is used for charac-ters 5, 6 and 7 to indicate that anapproach, device or qualifier was notapplicable for a specific procedure.

The body systems for medical and surgi-cal procedures are specified in the secondcharacter and are shown in Table 4. Inorder to provide necessary body partsdetail some traditional body systems are

assigned multiple body system categories.For example, body system categories K(Muscles), L (Tendons), M (Bursa, Liga-ments, Fascia), N (Head and FacialBones), P (Upper Bones), Q (LowerBones), R (Upper Joints) and S (LowerJoints) are subsystems of the Musculosk-eletal system.

ROOT OPERATIONS

The root operation is specified in thethird character. In the medical and surgicalsection there are 30 different root opera-tion terms as shown in Table 5.The root

1 2 3 4 5 6 7

Section

Body Part

Approach

Device

Qualifier

Body System

Root Operation

Body Systems

0 Central Nervous System

1 Peripheral Nervous System 2 Heart and Great Vessels

3 Upper Arteries

4 Lower Arteries5 Upper Veins

6 Lower Veins

7 Lymphatic and Hemic System8 Eye

9 Ear, Nose, Sinus

B Respiratory SystemC Mouth and Throat

D Gastrointestinal System

F Hepatobiliary System and PancreasG Endocrine System

H Skin and Breast

J Subcutaneous Tissue K Muscles

L Tendons

M Bursa, Ligaments, FasciaN Head and Facial Bones

P Upper Bones

Q Lower BonesR Upper Joints

S Lower Joints

T Urinary SystemV Female Reproductive System

W Male Reproductive System

X Anatomical RegionsY Upper Extremities

Z Lower Extremities

Table 4: Medical and Surgical Body Systems


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


operation specifies the underlying objec-tive of the procedure. Each root operationis given a very precise definition. Forexample, the term insertion is used for put-ting in or on devices. If a device is takenout but no equivalent device is put in thenthe root operation term removal is used.The term removal is only used for takingout or off devices. The root operation termextirpation is used when solid matter suchas a foreign body, embolus, clot, thrombusor stone is taken out of a body part withouttaking out any of the body part. The rootoperation term excision is used to indicatethat a portion of a body part was cut out,while the root operation term resection isused to indicate that all of a body part wascut out. If the body part that is cut out hasbiological or synthetic material substitutedfor it then the root operation term replace-ment is used. If the body part that is cutout has a living body part from a donor putin its place then the root operation termtransplantation is used. The above exam-ples of root operation terminology illus-trates the precision used to define theseterms. There is always a clear distinctionmade regarding the differences betweeneach root operation term.

A root operation must also constitute acomplete procedure. The term anastomo-sis is not a root operation since it is ameans of joining and is an integral part ofanother procedure such as a bypass or aresection. An anastomosis can never beperformed as a stand alone procedure.Similarly, incision is not a root term since itis a means of opening and is always anintegral part of another procedure.

Appendix A provides additional detail onthe root operations and Appendix B com-pares all root operations for the medicaland surgical section and provides anexample of each root operation.

BODY PART

The body part is specified in the fourthcharacter. The body part indicates thespecific part of the body system on whichthe procedure was performed (e.g.,duodenum).

APPROACH

The technique used to reach the site of the procedure (i.e., approach) is specified in the fifth character. There are 13 different approaches as shown in Table 7.

The approach is comprised of four com-ponents: the access location, method,type of instrumentation and route.

Access Location

For operations performed on an internalbody site, the access location specifies theexternal body site through which theinternal site of the operation is reached.There are two possible access locations:skin or mucous membrane and anexternal orifice. The skin or mucousmembrane can be cut through orpunctured by instruments in order to reachthe internal site of the operation. Theinternal site of an operation can also bereached through an external orifice.External orifices can be natural (e.g.,mouth) or artificial (e.g., colostomy stoma).

Method

The method specifies how the externalbody site is entered. An open methodinvolves cutting through the external bodylayer or lining of an orifice and any otherintervening body layers necessary toexpose the internal site of the operation.An instrumental method involves the entryof instrumentation through the accesslocation in order to reach the internal siteof the procedure. Instrumentation can beintroduced by puncture or minor incision orthrough an external orifice. The punctureor minor incision used to introduce theinstrumentation does not constitute an


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-scopic

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 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-nal Endoscopic

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 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 Endoscopic

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

Open With Cardiopulmo-nary Bypass

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

Open With Inflow Occlusion

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

Open With Temporary Shunt

Cutting through the skin or mucous membrane and any other body layers necessary to 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


open approach since it does not exposethe site of the procedure or expose anytubular body part. An approach caninvolve both methods. For example, aprocedure can include an open method toexpose a tubular body part followed by theintroduction of instrumentation into thetubular body part.

Type of Instrumentation

Instrumentation may include thecapability to visualize the site of theoperation. For example, theinstrumentation used to perform asigmoidoscopy permits the internal site ofthe operation to be visualized while theinstrumentation used to perform a needlebiopsy of the liver does not. The termendoscopic is used to refer toinstrumentation that permits a site to bevisualized.

Route

Instrumental methods may involve thepassage of instrumentation into the lumenof a tubular body part in order to reach theinternal site of the operation. Anintraluminal route indicates thatinstrumentation was passed into thelumen of a tubular body part.

Operations performed directly on theskin or mucous membrane constitute anexternal surface and therefore, theapproach is none (e.g., skin excision).Procedures performed indirectly by theapplication of external force also constitutean external site and the approach is none(e.g., closed repair of fracture). Table 6contains a definition of each approach.Appendix C compares the components ofeach different approach along with anexample of each approach. For cardiovas-cular procedures there are three additionalopen approaches which specify whethercardiopulmonary bypass, inflow occlusionor a temporary shunt was used during theprocedure.

DEVICE

The device is specified in the sixth char-acter and is only used to specify devicesthat remain after the procedure is com-pleted. There are four general types ofdevices:

1. Biological or synthetic material thattakes the place of all or a portion of abody part (e.g, skin grafts and jointprosthesis).

2. Biological or synthetic material thatassists or prevents a physiologicalfunction (e.g., IUD).

3. Therapeutic material that is notabsorbed by, eliminated by, orincorporated into a body part (e.g.,radioactive implant). Therapeuticmaterials that are considered devicescan always be removed.

4. Mechanical or electronic appliancesused to assist, monitor, take the placeof or prevent a physiological function(e.g., diaphragmatic pacemaker,orthopedic pins).

Devices can be used with the root oper-ations alteration, bypass, change, cre-ation, dilation, drainage, fusion, insertion,occlusion, reattachment, removal, repair,replacement, restriction and revision.Instruments that describe how a proce-dure is performed are not specified in thedevice character. The approach characterspecifies whether instrumentation is usedto reach or to reach and visualize the siteof the procedure. If the objective of theprocedure is to put in the device, then theroot operation is insertion. If the device isput in as a part of a procedure that has anunderlying objective other than the inser-tion of the device, then the root operationcorresponding to the underlying objectiveof the procedure is used with the devicespecified in the device character. Thus,even if the repair of a bone includes put-


ting in a fixation device, the root operationis repair and not insertion. Materials whichare incidental to a procedure such as clips,ligatures and sutures are not specified inthe device character. Since new devicescan be developed a “device NEC” option isprovided.

QUALIFIER

The qualifier is specified in the seventhcharacter. The qualifier has a uniquemeaning for individual procedures. Forexample, the qualifier can be used to iden-tify the second site included in a bypass.

Guidelines for Medical and Surgical Section

In developing the medical and surgicalprocedure codes, there were several spe-cific guidelines that were followed:

Composite Terms are not Root Operations

Root operations describe only theunderlying objective of the procedureitself. Thus, composite terms such ascolonoscopy and sigmoidectomy are notroot terms since they specify multipleaspects of a procedure. A diagnosticcolonoscopy is a composite of the rootoperation inspection (visual exploration),the body part (colon) and the instrumentused to visualize the site of the procedure(colonoscope). The precise part of thegastrointestinal tract which was inspectedwould be specified by the body part(character 4). A partial sigmoidectomy is acomposite of the root operation excisionand the body part sigmoid. A partialsigmoidectomy would be coded as anexcision (cut out, without replacement, aportion of a body part) at the body part,sigmoid. While the terms colonoscopy andsigmoidectomy would be in the Index theywould not constitute root entries in theTabular List.

Code Based on Objective of Procedure

The root term used to describe aprocedure is based on the objective of theprocedure. Thus, if a procedure isperformed in order to take out a foreignbody, then the procedure is coded as anextirpation. Dilating the urethra would becoded as dilation since the objective of theprocedure is to dilate the urethra. If thedilation of a urethra includes putting in anintraluminal device, the root operationremains a dilation and not an insertion ofthe intraluminal device since theunderlying objective of the procedure isthe dilation of the urethra.

Combination Procedures are CodedSeparately

If a procedure involves distinct parts,then multiple codes are used. Forexample, the obtaining of the vein graftused for coronary bypass surgery is codedas a separate procedure.

Revisions of Procedures

A revision of a procedure is doing overagain a portion of a previously performedprocedure that has failed to function asintended. Revisions do not include thecomplete doing over again of theprocedure which is considered the sameas the original procedure. Revisions alsodo not include the correction ofcomplications that do not require the doingover again of a portion of the originalprocedure such as the control of bleeding.Revision is a root operation term.Revisions can be done on a previouslyperformed alteration, bypass, creation,detachment, excision, fusion, insertion,occlusion, reattachment, repair,replacement, reposition, resection,restriction, transfer and transplantation.The specification of the original operationon which the revision is being performed isidentified in the qualifier character.Revisions can be performed on any


procedure which includes a device exceptthe root operation change. Revisions arefrequently performed on implantedmechanical appliances (e.g.,diaphragmatic pacemakers), or materialsused in replacements or repairs (e.g.,synthetic substitute). Thus, revisionencompasses the repositioning and fixingof malfunctions in devices. Revisions canalso be performed on any procedurewhich does not include a device but doesinclude an anastomosis (e.g., resection).

Specification of Approach

Many procedures can be accomplishedby different approaches. Except forprocedures on the skin or mucousmembrane, a specification of the approachis always required.

Examples of procedures coded in ICD-10-PCS

The following are several examples ofprocedures from the medical and surgicalsection coded in ICD-10-PCS.

Open reduction with internal fixation of lefttibia with plate and screws: 0QQH04Z

Medical and surgical section (0), bodysystem lower bones (Q), root operationrepair (Q), body part left tibia (H), openapproach (0) with internal fixation device(4) and without qualifier(Z).

Laparoscopic appendectomy:0DTJ4ZZ

Medical and surgical section (0), bodysystem gastrointestinal (D), root operationresection (T), body part appendix (J),percutaneous endoscopic approach (4),without device (Z) and without qualifier(Z).

Sigmoidoscopy with biopsy:0DBNZX

Medical and surgical section (0), bodysystem gastrointestinal (D), root operationexcision (B), body part sigmoid colon (N),transorifice intraluminal endoscopic

approach (8), without device (Z) and withqualifier diagnostic (X).

Tracheostomy: 0B110F5

Medical and surgical section (0), bodysystem respiratory (B), root operationbypass (1), body part trachea (1), openapproach (0), with tracheostomy device(F) and qualifier opening to the skin (5).

Obstetrics

The seven characters for the obstetricssection have the same meaning as in themedical and surgical section.

Obstetrical procedures have the firstcharacter specifying the section desig-nated with the number “1”. For the obstet-rical section the body system has only onevalue, “0” for pregnancy. The root opera-tions change, drainage, insertion, inspec-tion, removal, repair, reposition, resectionand transplantation are used in the obstet-ric section and have the same meaning asin the medical and surgical section. TheObstetrics section includes operationsperformed on the products of conceptiononly; operations on the pregnant femaleare coded in the medical and surgical sec-tion (e.g., episiotomy). The obstetrics sec-tion also includes two additional rootoperations, abortion and delivery whichare defined as:

A Cesarean Section does not constitutean additional root operation since it is a

Abortion: Artificially terminating a pregnancy

Delivery:Assisting the passage of the products of conception from the genital canal

1 2 3 4 5 6 7

Section

Body Part

Approach

Device

Qualifier

Body System

Root Operation


resection (i.e., cutting out all of a bodypart). The body parts for the obstetricalsections are:

Products of conceptionProducts of conception, retainedProducts of conception, ectopic

The term “products of conception” isused to refer to all components of a preg-nancy including the fetus, amnion, umbili-cal cord and placenta. There is nodifferentiation of the products of concep-tion based on gestational age. Thus, thespecification of the products of conceptionas a zygote, embryo or fetus or the trimes-ter of the pregnancy is not part of the pro-cedure code and would be obtained fromthe diagnosis code. The approaches forthe obstetrical section are the same as themedical and surgical section. The devicecharacter has the same definition as themedical and surgical section and is usedfor devices such as fetal monitoring elec-trodes. The qualifier character is specificto the root operation; it is used to specifythe type of delivery (e.g., low forceps, highforceps, etc.), the type of C-section (e.g.,classical, low cervical, etc.) or the type offluid taken out during a drainage (e.g.,amniotic fluid, fetal blood, etc.).

Placement Procedures

The seven characters for the placementsection have the following meaning:

Placement procedures, generally, referto putting a device in or on a body regionfor the purpose of protection, immobiliza-tion, stretching, compression or packing. Aplacement procedure always has a device

specified. Placement procedures have thefirst character specifying the section desig-nated with the number “2”. For the place-ment section the body region/orifice hasonly two values indicating either bodyregion or body orifice. The root operationschange and removal are used in the place-ment section and have the same meaningas in the medical and surgical section. Theplacement section also includes five addi-tional root operations which are defined asfollows.

The body regions for the placement sec-tion are either external body regions (e.g.,upper leg) or natural orifices. Since allplacement procedures are performed onan external body region or within an orificethe approach is always none. The devicecharacter is always specified and indicatesthe material or device used in the place-ment procedure (e.g., cast, splint, ban-dage, etc.). Except for casts for fracturesand dislocations, devices in the placementsection are off the shelf and do not requireany extensive design, fabrication or fitting.The placement of devices that requireextensive design, fabrication or fitting arecoded in the rehabilitation section. Thequalifier character is not used in the place-ment section.

Administration

The seven characters for the administra-tion section have the following meaning:

1 2 3 4 5 6 7

Section

Body Region/

Approach

Device

Qualifier

Anatomical Regions

Root Operation

/Orifices Orifice

Compression: Putting pressure on an external body part

Dressing: Putting material on an external body part for protection

Immobilization: Limiting or preventing motion of an external body part

Packing: Putting material in a body partTraction: Exerting a pulling force on an exter-

nal body part in a distal direction


Administration procedures refer to theputting in or on a therapeutic, prophylactic,protective, diagnostic, nutritional or physi-ological substance. Administration proce-dures have the first character specifyingthe section designated with the number“3”. For the administration section thebody system has only two values indicat-ing physiological system and anatomicalregion or circulatory system. The circula-tory body system is used for transfusionprocedures. There are three root opera-tions for the administration section.

The fourth character specifies the bodysystem/region which is the site where theadministration occurs and not the sitewhere the substance administered has aneffect. The sites include skin and mucousmembrane, subcutaneous tissue andmuscle which are used to differentiateintradermal, subcutaneous and intramus-cular injections. Character 5 specifies theapproach and has the same meaning as inthe medical and surgical section. Theapproach for intradermal, subcutaneousand intramuscular introductions (i.e., injec-tions) would be percutaneous. If a catheteris used to introduce a substance into aninternal site within the circulatory system,then the approach would be percutaneousintraluminal. Thus, if a catheter is used to

introduce contrast directly into the heartfor angiography, then the procedure wouldbe coded as a percutaneous intraluminalintroduction of contrast into the heart.

The body systems/regions for arteriesand veins are peripheral artery, centralartery, peripheral vein and central vein.The peripheral artery or vein is used whena substance is introduced locally into anartery or vein. For example, chemotherapywould be the introduction of an antineo-plastic substance into a peripheral arteryor vein by a percutaneous intraluminalapproach. In general, the substance intro-duced into a peripheral artery or vein hasa systemic effect and not a local effect.

The central artery or vein is used whenthe site within the artery or vein where thesubstance is introduced is distant from thepoint of entry of the instrumentation intothe artery or vein. The introduction of asubstance using a catheter directly at thesite of a clot within an artery or vein wouldbe coded as an introduction of a throm-bolytic substance into a central artery orvein by a percutaneous intraluminalapproach. In general, the substance intro-duced into a central artery or vein has alocal effect.

The sixth character specifies the sub-stance being introduced. There are broadcategories of substances, such as anes-thetics, contrast, or dialysate, plus bloodproducts specified in Character 6.

Character 7 is a qualifier and is used toindicate whether the introduction is singleor continuous. Continuous introductionsare used to specify that the introduction ofthe substance required more than 15 min-utes. A standard IV would be a continuousintroduction of an electrolytic and waterbalance substance into a peripheral veinby a percutaneous intraluminal approach.For the circulatory body system, the quali-

Introduction: Putting in or on a therapeutic, diagnostic, nutritional, physiological or prophylactic substance except blood or blood products

Irrigation: Putting in or on and retrieving a liquid substance

Transfusion: Putting in blood or blood products

1 2 3 4 5 6 7

Section

Body/System

Approach

Substance

Qualifier

Physiological Systems

Root Operation

& Anatomical Regions Region


fiers autologous and nonautologous areused to describe the substance adminis-tered.

Measurement and Monitoring

The characters for the measuring andmonitoring section have the followingmeaning:

Measurement and monitoring proce-dures refer to the determination of thelevel of a physiological or physical func-tion. If the equipment used to perform themeasurement or monitoring is a devicethat is inserted and left in, then the inser-tion of the device is coded as a separateprocedure. Measurement and monitoringprocedures have the first character speci-fying the section designated with the num-ber 4. For the measurement andmonitoring section, the physiological sys-tem has only one value. There are tworoot operations in the measurement andmonitoring section which are defined as:

The fourth character specifies the spe-cific body system which is being measuredor monitored. The fifth character specifiesthe approach which has the same mean-ing as the medical and surgical section.The sixth character specifies the precisephysiological or physical function beingmeasured or monitored. Examples ofphysiological or physical functions wouldbe conductivity, metabolism, pulse, tem-perature or volume. The seventh character

is the qualifier which is unique for eachprocedure. An EKG would be the mea-surement of cardiac electrical activity whilean EEG would be the measurement ofelectrical activity of the central nervoussystem. A cardiac catheterization per-formed to measure the pressure in theheart would be coded as the measure-ment of cardiac pressure by a percutane-ous intraluminal approach.

Osteopathic

The seven characters for the osteo-pathic section have the following meaning:

Osteopathic procedures have the firstcharacter specifying the section desig-nated with the number “8”. For the osteo-pathic section, the body system characterhas only one value, anatomical regions.There is only one root operation in theosteopathic section.

The fourth character specifies the bodyregion on which the osteopathic manipula-tion is performed. The approach for osteo-pathic manipulations is always none. Thesixth character is the method which speci-fies the means by which the manipulationis accomplished. The seventh character isnot used in the osteopathic section andalways has the value none.

Extracorporeal Assistance and Performance

The seven characters for the extracor-poreal assistance and performance sec-tion have the following meaning:

Measurement: Determining the level of a physiological or physical function at a point in time

Monitoring: Determining the level of a physiological or physical function repetitively over a period of time

1 2 3 4 5 6 7

Section

Body System

Approach

Function

Qualifier


Root Operation

Treatment: Manual treatment to eliminate or alleviate somatic dysfunction and related disorders

1 2 3 4 5 6 7

Section

Body Region

Approach

Method

Qualifier

Anatomical Regions

Root Operation


In an extracorporeal assistance and per-formance procedure, equipment externalto the body is used to assist or perform aphysiological function. Extracorporealassistance and performance procedureshave the first character specifying the sec-tion designated with the letter “B”. For theextracorporeal assistance and perfor-mance section, the physiological systemhas only one value. There are three rootoperations in the extracorporeal assis-tance and performance section.

The fourth character specifies the bodysystem (e.g., cardiac, respiratory, etc.) forwhich extracorporeal assistance or perfor-mance is being used. The fifth characterspecifies the duration of the extracorporealassistance or performance (i.e., single,intermittent or continuous). For respiratoryventilation assistance or performance, therange of hours is specified (96 hours). The sixth charac-ter specifies the physiological functionbeing assisted or performed (e.g., oxygen-ation, ventilation, etc.). The seventh char-acter is a qualifier which specifies the typeof equipment used in the extracorporealassistance or performance.

Extracorporeal Therapies

The seven characters for the extracor-poreal therapies section have the followingmeaning:

In an extracorporeal therapy, equipmentexternal to the body is used for a thera-peutic purpose that does not involve theassistance or performance of physiologicalfunction. Extracorporeal therapies havethe first character specifying the sectiondesignated with the letter “C”. For theextracorporeal therapy section, the physio-logical system has only one value. Thereare six root operations in the extracorpo-real therapy section.

The fourth character specifies the bodysystem on which the extracorporeal ther-apy is performed (e.g., skin, circulatory,etc.). The fifth character specifies theduration of the extracorporeal therapy(e.g., single or intermittent). The sixthcharacter is not used for extracorporealtherapies and always has the value none.The seventh character is a qualifier whichis only used to specify the components ofthe circulatory system on which pheresisis performed.

Imaging Procedures

The seven characters for imaging proce-dures have the following meaning:

Assistance: Taking over a portion of a physiological function by extracorporeal means

Performance: Completely taking over a physiological function by extracorporeal means

Restoration: Returning, or attempting to return, a physiological function to its natural state by extracorporeal means

1 2 3 4 5 6 7

Section

Body System

Duration

Function

Qualifier


Root Operation

Decompression: Extracorporeal elimination of undissolved gas from body fluids

Hyperthermia: Extracorporeal raising of body temperature

Hypothermia: Extracorporeal lowering of body temperature

Pheresis: Extracorporeal separation of blood products

Phototherapy: Extracorporeal treatment by light rays

Ultraviolet Light Therapy:

Extracorporeal treatment by ultraviolet light

1 2 3 4 5 6 7

Section

Body System

Duration

Qualifier

Qualifier


Root Operation


The section for imaging procedures isindicated by the number “5” in the firstcharacter. Imaging procedures includeplain film, Fluoroscopy, CT, MRI, and Ultra-sound. Nuclear medicine proceduresincluding PET, uptakes and scans are inthe nuclear medicine section and thera-peutic radiology is in the radiation oncol-ogy section.

The second character is the body sys-tem and the fourth character is the bodypart. The third character is the root type ofimaging procedure (e.g, MRI, Ultrasound,etc.). Table 7 contains the list of all roottypes for the imaging section with a defini-tion of each root type. The fifth characterspecifies the type of contrast materialused in the imaging procedure (e.g., highor low osmolar). When the concentrationof the contrast is not relevant (e.g., air) orfor MRIs (e.g., Gadoteridol) the specificcontrast is specified. An “Identification NotRequested” option is allowed for character5 in the imaging section to be used in hos-pitals and other institutions where detailedinformation about contrast material is notrequested by the payor.

The sixth character provides either fur-

ther detail about the contrast material suchas specifying the route of administration(e.g., IV, direct, via colostomy) or containsa qualifier specific to the root type of imag-ing procedure. For example, for plain radi-ography procedures without contrast,character 6 indicates if the procedure wasdone at the bedside (portable).

The seventh character is a qualifier thathas a unique meaning for individual imag-ing procedures. (e.g., Cine evaluation,plain film subtraction, etc.)

Contrast (character 5), contrast/qualifier(character 6) and qualifier (character 7)are not applicable to all imaging proce-dures.

Nuclear Medicine

The seven characters for the nuclearmedicine section have the followingmeaning:

Nuclear medicine is the introduction ofradioactive material into the body in orderto create an image, to diagnose and treatpathologic conditions and to assess meta-bolic functions. The nuclear medicine sec-

1 2 3 4 5 6 7

Section

Body Part

Contrast

Contrast/Qualifier

Qualifier

Body System

Root Type

1 2 3 4 5 6 7

Section

Body Part

Radionuclide

Radiopharmaceutical

Qualifier

Body System

Type

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-phy (CT Scan)

Computer-reformatted digital display of multiplanar images developed from the capture of multiple exposures of external ionizing radiation.

Magnetic Resonance Imaging (MRI)

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

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


tion does not include the introduction ofencapsulated radioactive material for thetreatment of oncologic disease which isincluded in the radiation oncology section.

Nuclear medicine procedures have thefirst character specifying the section desig-nated by the number “6”. The secondcharacter represents the body system onwhich the nuclear medicine procedure isperformed. The third character indicatesthe type of nuclear medicine procedure(e.g., planar imaging or non-imaginguptake). Table 8 contains the list of thetypes of nuclear medicine procedures witha definition of each type.

The fourth character indicates the bodypart or body region being studied.

Regional (e.g., lower extremity veins)and combination (e.g., liver and spleen)body parts are commonly used in this sec-tion.

The fifth and sixth characters togetherspecify the radiopharmaceutical used inthe nuclear medicine procedure. Charac-

ter 5 specifies the radionuclide which isthe source of the radiation and character 6specifies the radiopharmaceutical agent.

As with devices in the medical and surgi-cal section, a “not elsewhere classified”(NEC) option is included in the nuclearmedicine section to be used for newlyapproved radiopharmaceuticals until theycan be explicitly added to the coding sys-tem. An “Identification Not Requested”option is allowed for characters 5 and 6 inthe nuclear medicine section to be used inhospitals and other institutions wherereporting of the radiopharmaceutical is notrequested by the payor.

The seventh character is a qualifier andprovides further details on the specificnuclear medicine procedure performed.For example, the qualifiers used withtomographic imaging of the heart includerest, stress and wall motion.

If more than one introduction of radiop-harmaceutical is carried out then morethan 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-graphic (PET) Imaging

Introduction of radioactive materials into the body for three dimensional display of 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


nuclear medicine procedure. For example,a thallium scan of the heart during stressand at rest will have both a code for thestress study and a second code for a reststudy. When the procedure has two imag-ing sessions performed at different times,but not an additional administration of aradiopharmaceutical, the two imaging pro-cedures are noted in the qualifier column.For example, a stress with redistributionthallium study has a qualifier to indicatethe two separate imaging sessions.

Occasionally two radiopharmaceuticalsare used for a nuclear medicine proce-dure, and imaging is done simultaneously.Two distinct codes are used, because tworadiopharmaceutical introductions havebeen done.

Radiation Oncology

The seven characters for radiationoncology procedures have the followingmeaning:

The section for radiation oncology isindicated by the number “7” in the firstcharacter. The radiation oncology sectionincludes all radiation oncology proce-dures, including all treatment simulationsand medical physics treatment supportprocedures performed as part of radiationoncology. The second character is thebody system (e.g., Central Nervous Sys-tem, Musculoskeletal) which is being irra-diated. The third character specifies themodality or type of radiation which is beingused (e.g., photons, electrons). The fourthcharacter specifies the body part that isthe target of the radiation therapy. Charac-ter 5 provides a count of the ports used or

the isotopes introduced into the body.Ports are the number of beams directed atthe body part which is receiving the radia-tion. Character 6 specifies the equipmentused during a radiation oncology proce-dure. The equipment includes externalprotective devices which may be prefabri-cated or custom designed and constructedspecifically for individual patients, implantdevices and other devices which are anintegral part of the radiation oncology pro-cedure (e.g., Gamma Knife). Character 7represents a qualifier to the radiationoncology procedure. For radiation oncol-ogy treatments and simulations, character7 specifies the risk structures that aretaken into account as part of the interven-tion (e.g., eye, brain stem, spinal cord).The risk structures are body parts thatmay be exposed to radiation and must betaken into account during the radiationoncology procedure.

For medical physics procedures, thequalifier identifies the specific medicalphysics activity performed (e.g., dosime-try, irregular field calculation.

An “Identification Not Requested” optionis allowed for characters 5,6 and 7 in theradiation oncology section and is used inhospitals and other institutions wherereporting this level of detail is notrequested by the payor.

Rehabilitation and Diagnostic Audiology

The seven characters for the rehabilita-tion and diagnostic audiology section havethe following meaning:

1 2 3 4 5 6 7

Section

Treatment Site

Ports/Isotopes

Device

Qualifier/

Body System

ModalityRisk

Structure

1 2 3 4 5 6 7

Section Test/Method

Body Part/System QualifierType

Equipment


Rehabilitation procedures include physi-cal therapy, occupational therapy andspeech-language pathology. Osteopathicprocedures and chiropractic proceduresare in separate sections. Rehabilitationand diagnostic audiology procedures havethe first character specified with the num-ber “9”. The type of procedure is specifiedin the second character. There are 4 differ-ent types of rehabilitation and diagnosticaudiology procedures which are definedas follows:

The root operation treatment includestraining as well as activities which restorefunction. The third and fourth charactersspecify the exact test or method employed.For example, therapy to improve the rangeof motion as well as training for bathingtechniques are two different types of treat-ment. The fifth character is the body partor system for which the procedure is beingperformed. Character 6 specifies the typeof equipment used. Specific types ofequipment are not specified. Rather, broadcategories of equipment are specified(e.g., aerobic endurance and conditioningequipment, assistive/adaptive/supportivedevices, etc.) The seventh character is aqualifier and is only used for certain test/methods to specify whether the test/method is group or individual.

Chiropractic

The seven characters for the chiropracticsection have the following meaning:

Chiropractic procedures have the firstcharacter specifying the section desig-nated with the letter “G”. For the chiroprac-tic section, the body system has only onevalue. There is only one root operation inthe chiropractic section.

The fourth character specifies the bodysite on which the chiropractic manipulationis performed. The approach for chiroprac-tic manipulation is always none. The sixthcharacter is the method which specifiesthe means by which the manipulation isaccomplished. The seventh character isnot used in the chiropractic section andalways has the value none.

Mental Health

The seven characters for the mentalhealth section have the following meaning:

The mental health section providescodes to describe the full range of ser-vices provided by psychiatrists and othermental health professionals. The first char-acter for Mental Health procedures is “F”.The second character specifies the type ofprocedure, such as crisis intervention, orcounseling. The third character is for pro-

Treatment: Use of specific activities or methods to develop, improve and/or restore the per-formance of necessary functions, com-pensate for dysfunction and/or minimize debilitation.

Assessment: Includes a determination of the patient’s diagnosis when appropriate, need for treatment, planning for treatment, peri-odic assessment and documentation related to these activities.

Fitting(s): Design, fabrication, modification, selec-tion and/or application of splint, orthosis, prosthesis, hearing aids and/or other rehabilitation device.

Caregiver Training:

Educating caregiver with the skills and knowledge used to interact with and assist the patient.

Treatment: Manual treatment of the musculoskeletal system to restore normal neurophysiologi-cal function

1 2 3 4 5 6 7

Section

Body Region

Approach

Method

Qualifier

Anatomical Regions

Root Operation

1 2 3 4 5 6 7

Section

Qualifier

Qualifier

Qualifier

Qualifier

Type

Type Expansion


cedure type expansion (e.g., to indicatethat counseling was educational or voca-tional). The fourth character is a qualifier.Characters 5,6 and 7 are never used andalways have the value of none.

Laboratory Procedures

The seven characters for the laboratorysection have the following meaning:

Laboratory procedure codes are identi-fied by the letter “D” in the first character.

The second character, the analyte class,is a categorization of the major classes oftests that are performed. There are sixmajor classes and two extensions, in thelaboratory section: Blood Bank, Hematol-ogy, Chemistry and Other Chemistry,Microbiology and Other Microbiology, Toxi-cology and Pathology.

The third and fourth characters specifythe analyte, (i.e., the material being identi-fied or measured for each analyte class)(e.g., calcium, hematocrit). The fifth andsixth characters identify the specimen ifapplicable (e.g., cerebral spinal fluid).

Character seven is the method used inthe analysis (e.g., stain, culture). It is notalways necessary to specify the method tobe used in a laboratory test. When a spe-cific method is not requested, standardmethod is used in character seven.

Miscellaneous

The seven characters for the miscella-neous section have the following meaning:

The miscellaneous section includes acu-puncture, therapeutic massage and yogatherapy. The first character for miscella-neous section procedures is “H”. The onevalue for body system is “anatomicalregion”. The miscellaneous section hasonly one root operation which is defined asfollows:

There is only one body region indicatingthe whole body. There is no approach, sothe approach is always none. Character 6designates the method (i.e., Acupuncture,Therapeutic Massage or Yoga Therapy).There are no qualifiers, so none is alwaysassigned to the seventh character.

Modifications to ICD-10-PCS

Throughout the development of ICD-10-PCS, extensive input from a wide range oforganizations was obtained. A TechnicalAdvisory Panel which included represen-tatives from the American Health Informa-tion Management Association, AmericanHospital Association and the AmericanMedical Association provided review andcomment throughout the development ofICD-10-PCS.

The initial draft of ICD-10-PCS waswidely disseminated. Both a paper andcomputerized version of the system weremade available. Copies of ICD-10-PCSwere distributed to all major physician spe-cialty societies. HCFA made ICD-10-PCSavailable on its web site.

As a result of feedback from the exten-sive review of ICD-10-PCS, the systemwas modified from its initial version to

1 2 3 4 5 6 7

Section Analyte

MethodAnalyteClass

Specimen Source Other Therapies: Methodologies which attempt to remedi-ate or cure a disorder or disease.

1 2 3 4 5 6 7

Section

Body Region

Approach

Method

Qualifier

Body System

Root Operation


reflect the suggestions from the reviewers.The most frequent issue identified byreviews was missing tabular entries, (i.e.,procedures were identified for which therewas no corresponding tabular entry). Miss-ing tabular entries most often related tothe need to allow additional approachesfor a specific procedure (e.g., a wide rangeof procedures that previously could onlybe performed by an open approach cannow be performed by a percutaneous orpercutaneous endoscopic approach). Sev-eral additional root operations weredefined in the medical and surgical section(e.g., fusion). The approaches were sim-plified. Originally, there were 17 differentapproaches. The approaches that speci-fied that the access location was the liningof an orifice or was within the orifice itselfwere eliminated. These approaches didnot constitute a critical distinction indescribing the procedure performed.These approaches were incorporated intothe other approaches by modifying thedefinition of some of the otherapproaches. These changes reduced thenumber of approaches to 13. Biopsy is nota root operation since it is usually a form ofan excision. Many reviewers suggestedthat it was important to distinguish biop-sies from therapeutic excisions. Therefore,a qualifier specifying that the excision wasdiagnostic was added.

One of the most frequent issues raisedconcerning ICD-10-PCS was the issue ofNOS codes. The concern was that suffi-cient specificity of documentation may notbe present in the medical record to sup-port the detail required by ICD-10-PCS.Originally, ICD-10-PCS did not provide forNOS codes. As a result of these concerns,modifications were made to ICD-10-PCSto address this issue. Since ICD-10-PCSis a multi-axial system, the NOS issue wasaddressed separately for each character.

In the Medical and Surgical section, theNOS issue primarily relates to the rootoperation, body part and approach charac-ters. The operation repair is an operationof exclusion. Most of the other 29 rootoperations constitute some type of repair.However, if the objective of the proceduremeets the definition of one of the otherroot operations then repair is not coded.Repair is only coded when none of theother operations apply. In essence, repairis the NOS option for the root operationcharacter. The ICD-10-PCS codinginstructions were modified to indicate thatif the root operation can not be determinedfrom the documentation and the neces-sary information could not be obtainedfrom the physician, then the root opera-tions repair should be coded.

In order to address the issue of insuffi-cient anatomic specificity in the medicalrecord, the use of generic body parts wasexpanded. If the precise body part was notspecified, then the option of coding ageneric body part was added. For exam-ple, originally, for excision of the liver theprecise part of the liver excised wasrequired (i.e., right lobe, left lobe or cau-date lobe). The generic body part “liver”was added as an option. Thus, if the docu-mentation in the medical record does notindicate the precise part of the liver andthe specification of the precise body partof the liver could not be obtained from thephysician, then the coder has the option ofsimply coding the body part as liver. Thisin essence, provides the user with a “liverNOS” option. The coder will still need toidentify the broad anatomic regions but willhave a coding option when the full ana-tomic detail is not available in the medicalrecord and the necessary informationcould not be obtained from the physician.

There are four broad approach types:open, percutaneous, transorifice and


none. The ICD-10-PCS coding instruc-tions were modified to indicate that if thefull detail on the type of approach can notbe determined, then the most basic open,percutaneous or transorifice approachshould be coded. Minimally, the coder willstill need to be able to specify whether theapproach was open, percutaneous, tran-sorifice or none. This distinction is so fun-damental to the description of theprocedure that any less specificity relativeto the approach would not be appropriate.

While the NOS issue primarily related tothe medical and surgical section, therewere also NOS related issues in some ofthe other sections of ICD-10-PCS. Theimaging, nuclear medicine and radiationoncology sections of ICD-10-PCS allowthe reporting of detail relating to the proce-dure that may not be readily available inthe hospital medical record. Further, inthese sections the level of detail allowedby ICD-10-PCS, while important for inter-nal management, may not be required bypayors. For the characters in these sec-tions where the full detail of ICD-10-PCSmay not be required an “Identification NotRequested” option is provided. The sec-tions and characters for which an Identifi-cation Not Requested Option is providedare summarized in Table 9.

The Identification Not Requested optionallows the procedure to be coded exclud-ing the detail specified in the characters in

Table 9.

The modifications made to ICD-10-PCSto address the NOS issue strike a balancebetween a precise description of the pro-cedure and the realities of the currentstate of medical records documentation.

Number of Codes in ICD-10-PCS

Table 10 summarizes the number ofcodes by section in the final draft of ICD-10-PCS. The number in parethesis for theimaging, nuclear medicine and radiationoncology sections specify the number ofadditional codes that would be present ifthe full detail associated with the Identifi-cation Not Requested characters in Table9 were included.

There are a total of 197,769 codes inICD-10-PCS which represents a substan-tial increase in the number of codes rela-tive to ICD-9-CM procedure codes. The

Section Character

Imaging Character 5 - Contrast

Nuclear Medicine Character 5 - RadionuclideCharacter 6 - Radiopharmaceutical

Radiation Oncology Character 5 - Ports/IsotopesCharacter 6 - DeviceCharacter 7 - Risk structure

Table 9: Sections and characters for which an Identification Not Requested option is provided

SectionNumber of

Codes

Medical and Surgical 176,367

Obstetrics 322

Placement 831

Administration 1,228

Measurement and Monitoring 224

Imaging 9,433 (13,141)

Nuclear Medicine 365 (1,011)

Radiation Oncology 1,225 (308,015)

Osteopathic 100

Rehabilitation and Diagnostic Audiology

1,705

Extracorporeal Assistance and Performance

28

Extracorporeal Therapies 20

Laboratory 2,681

Mental Health 283

Chiropractic 100

Miscellaneous 3

Total 194,915

Table 10: Number of ICD-10-PCS codes by section


grid structure of ICD-10-PCS permits thespecification of a large number of codeson a single page in the Tabular division.The combined Tabular and Index divisionsof ICD-10-PCS are 1,087 pages which isapproximately half the size of the Tabularand Index in the ICD-10 diagnosis codingmanual from the World Health Organiza-tion.

Testing of ICD-10-PCS

As an informal test in October 1996,seventy health information professionalswere trained in ICD-10-PCS. After thetraining, they coded a sample of recordsfrom their institutions using ICD-10-PCSand reported suggestions and problems tothe ICD-10-PCS project staff.

HCFA conducted a formal test of ICD-10-PCS in order to determine if it would be apractical replacement for the current ICD-9-CM procedures. HCFA used two con-tractors to evaluate ICD-10-PCS. The con-tractors were the two Clinical DataAbstraction Centers (CDACs): DynKePROin York, PA, and FMAS in Columbia, MD.

As part of a contract awarded in 1994,the primary task of the CDACs has beento collect clinical data from about 1.5 mil-lion medical records over five years. Theprimary end product of the CDAC con-tracts was the development of accurateand reliable clinical data in quantities suffi-cient to support the analytical efforts of thePROs as they carry out the Health CareQuality Improvement Program. Since theCDACs had a ready supply of currentmedical records and extensive experiencein reviewing, abstracting and coding medi-cal records, they were selected to testICD-10-PCS.

Using the ICD-10-PCS training manual,the CDACs were trained for two days onthe medical/surgical part of the system,

and a separate one-day session was heldfor the remaining sections (nuclear medi-cine, radiation oncology osteopathic, etc.)The CDACs then spent several weekscoding with ICD-10-PCS to gain experi-ence. Conference calls were held toanswer questions prior to the start of theformal testing.

In the first phase of the test, a sample of5000 medical records (2500 per CDAC)was selected, identifying cases with awide distribution of ICD-9-CM procedurecodes. The CDACs coded the cases usingICD-10-PCS and noted any questions orconcerns. These questions and otherissues were forwarded to project staff,which then responded on an ongoingbasis. As a result of this interaction, a listof revisions to the final draft was made.This included terms that needed clarifica-tion and omissions in the tabular list orindex sections. In addition, areas wherethe training manual could be improvedwere identified.

In the second phase of the test, a subsetof 100 medical records was recodedblindly using both ICD-9-CM and ICD-10-PCS. The reviewers coded the initial 50records first with ICD-9-CM, then withICD-10-PCS. For the last 50 records, theyreversed the process and began with ICD-10-PCS. The systems were compared onissues such as ease of use, time neededto identify codes, number of codesrequired, problems identifying codes,strengths and weaknesses of each sys-tem, and any other issues identified by thecoding personnel.

After an initial learning curve, the CDACcoders were able to use ICD-10-PCS eas-ily, with a few challenges. Because of theadded detail in ICD-10-PCS, it was occa-sionally necessary for the coders to utilizea medical dictionary or an anatomy text-book. The coders required a greater


understanding of anatomy and surgicalterms to use ICD-10-PCS than is requiredfor ICD-9-CM. As a result a greateramount of training time will be necessaryfor ICD-10-PCS than is currently requiredfor ICD-9-CM. Although the initial ICD-10-PCS training manual was very useful, theCDACS felt that it needed to be strength-ened with additional examples before anynational training takes place. It was alsosuggested by the CDACs that the additionof diagrams of the body systems would beuseful in the training manual.

Once the CDAC coders became profi-cient in ICD-10-PCS, they were able tosuggest a number of improvements, suchas additional index entries and revisions tothe body site and approach characters.These suggestions were included in thefinal draft of ICD-10-PCS. The testingpointed out the ease with which ICD-10-PCS can be updated and expanded whenissues are identified. Another area of con-cern was correct code assignment forrecords that did not provide enough docu-mentation of a specific site or the type ofprocedure or when the coders did nothave enough knowledge of anatomy toselect a precise code. The concernsresulted in the modification of the ICD-10-PCS coding rules to address this issue.

A side-by-side comparison of ICD-10-PCS and ICD-9-CM was performed whenthe coders became proficient with the useof the new system. One CDAC reportedthat the staff did not detect a significanttime difference in using ICD-10-PCS ascompared to ICD-9-CM. The other CDACfound that ICD-10-PCS coding took some-what longer. ICD-10-PCS sometimesrequired a greater number of codes thanICD-9-CM. This was due in part to the usein ICD-9-CM of more combination codesthan in ICD-10-PCS. However, it was feltthat the precision of ICD-10-PCS resulted

in greater detail about the nature of theprocedure and was therefore worthwhile. Itwas suggested that once coders becamefamiliar with the greater detail and preci-sion of ICD-10-PCS, the result would beimproved accuracy and efficiency of cod-ing.

Both CDACs pointed out that once thecoders were familiar with ICD-10-PCS,they rarely used the index. The ICD-10-PCS system was found to be so well orga-nized and so well structured that coderscould quickly find the correct section of thetabular list. The index was used moreoften when the coder was just learning thedefinitions of the root procedures and theother basic terms used in ICD-10-PCS.However, once coders understood ICD-10-PCS, they found it easy to code fromthe tabular section.

Both CDACs found ICD-10-PCS to bean improvement over ICD-9-CM as it pro-vided greater specificity in coding for usein research, statistical analysis, andadministrative areas. A major strength ofthe system was its detailed structure,which allowed users to recognize andreport more precisely the procedures thatwere performed.

Comparison of ICD-10-PCS and ICD-9-CM

In 1993, the National Committee on Vital& Health Statistics (NCVHS) issued areport concerning recommendations for asingle procedure classification system. Aspart of this report, NCVHS identified theessential characteristics that a procedureclassification system should possess. Thecharacteristics listed in Table 11 are takendirectly from the NCVHS report and sum-marizes the essential characteristics of aprocedure coding system. Included inTable 11 is a comparison of ICD-9-CM and


3M H

IS R

esearch R

epo

rt 4-9825

ICD-10-PCS

ability to aggregate across all essential compo-ts of a procedure is provided

codes have a unique definition

ensive flexibility procedures and technologies are easily incorpo-d. Unlimited empty code numbers available

ate process needs to be established. If ICD-10-S replaces ICD-9-CM, Coordination and Mainte-ce Committee would be responsible for update cess

e expansions do not disrupt systematic structure

ited use of NOS and NEC categories. NEC and S categories are specific to each axis of code. All cedures can be categorized somewhere. Proce-e codes are precisely defined even when NOS NEC options are used

types of procedures are included except evalua- and management procedures. Complete detail is vided for all types of procedures

settings and types of providers are covered except sician office services for evaluation and manage-nt. Complete detail is provided for all settings and es of providers

h procedure is assigned to only one code

Characteristics

NCVHS Characteristics ICD-9-CM

Hierarchical structure

Ability to aggregate data from individual codes into larger categories

The ability to aggregate by body system is provided but there is no ability to aggregate by other compo-nents of a procedure

Thenen

Each code has a unique definition forever - not reused Some codes do not have a unique definition because the codes have been reused

All

Expandibility

Flexibility to new procedures and technologies (“empty” code numbers)

Minimal flexibilityNew procedures and technologies are difficult to incorporate. Virtually no empty code numbers

ExtNewrate

Mechanism for periodic updating Updated annually through Coordination and Mainte-nance Committee

UpdPCnanpro

Code expansion must not disrupt systematic code structure

Code expansions are difficult to incorporate without disrupting systematic code structure

Cod

Comprehensive

Provides NOS and NEC categories so that all possible procedures can be classified somewhere

Extensive use of NOS and NEC categories. All pro-cedures can be categorized somewhere. Broad NOS and NEC categories result in procedure codes which are ambiguously defined

LimNOprodurand

Includes all types of procedures All types of procedures are included although there is minimal detail for many types of procedure

All tionpro

Applicability to all setting and types of providers All settings and types of providers are covered although there is minimal detail for many settings and types of providers

All phymetyp

Non-Overlapping

Each procedure (or component of a procedure) is assigned to only one code

The same procedure when performed for different diagnoses is sometimes assigned to multiple codes

Eac

Table 11: Comparison of ICD-9-CM and ICD-10-PCS Using the NCVHS

263M

HIS

Research

Rep

ort 4-98

Ease of

Standard ogy is precisely defined. All terminology is antly across all codes

Adequat ndex is computer generated so specificity consistent across codes

Setting

Same coperforme

independent of who or where procedure is

Multi-ax

Body sysharacter in the code specifies the body cted

Technolo used is specified in the approach charac-de

Techniquues/approaches used are specified in the haracter of the code

Physioloal effect and pharmacological properties d when relevant to the procedure

Characteteristics/composition of implants are spec-device character of the code

Limited

Should n tic information is included in the code

Other dawhere in

ta elements included in code

ICD-10-PCS

s (Continued)

Use

ization of definitions and terminology No standard definitions provided. Terminology is inconsistent across codes

All terminolused const

e indexing and annotation for all users Full index but specificity of index varies across codes

Full index. Iof index is

and Provider Neutrality

de regardless of who or where procedure is d

Codes are independent of who or where procedure is performed

Codes are performed

ial

tem(s) affectedBody system affected can be determined from code number

A specific csystem effe

gy usedLimited and inconsistent specification of technology used

Technologyter of the co

es/approaches usedLimited and inconsistent specification of techniques/approaches used

The techniqapproach c

gical effect or pharmacological propertiesLimited and inconsistent specification of physiologi-cal effect and pharmacological properties

Physiologicare specifie

ristics/composition of implantLimited an inconsistent specification of characteris-tics/composition of implant

The characified in the

to Classification of Procedures

ot include diagnostic information Diagnostic information is included for some codes No diagnos

ta elements (such as age) should be else- the record

No other data elements included in code No other da

NCVHS Characteristics ICD-9-CM

Table 11: Comparison of ICD-9-CM and ICD-10-PCS Using the NCVHS Characteristic

ICD-10-PCS across each of the NCVHScharacteristics. As the comparisons inTable 11 indicate, ICD-10-PCS meets vir-tually all the NCVHS characteristics whileICD-9-CM fails to meet many of theNCVHS characteristics.

In addition to the NCVHS characteris-tics, there are several other attributes of aprocedure coding system that should betaken into consideration when comparingsystems.

Training Effort

As the independent evaluation of ICD-10-PCS demonstrated there a is learningcurve associated with ICD-10-PCS. Sincethe CDAC staff were trained ICD-9-CMcoders, the independent evaluation did notinclude a formal comparison of the trainingtime for ICD-10-PCS and ICD-9-CM. How-ever, because of the additional specificityof ICD-10-PCS it is likely that the trainingtime needed to achieve a minimum level ofcoding proficiency is greater with ICD-10-PCS than with ICD-9-CM. While it maytake longer to reach a minimum level ofproficiency with ICD-10-PCS, it shouldtake less time to become highly proficientwith ICD-10-PCS than with ICD-9-CM.Because ICD-9-CM lacks clear definitionsand many substantially different proce-dures are coded with the same code, theidentification of the correct code requiresextensive knowledge of the contents ofCoding Clinic and other coding guidelines.Becoming completely familiar with all theconventions associated with ICD-9-CMrequires extensive effort and as a result,the process of becoming highly proficientin ICD-9-CM can require a long learningcurve.

Completeness and Accuracy of Codes

The CDACs concluded that procedurescoded in ICD-10-PCS provided a muchmore complete and accurate description of

the procedure performed. The specifica-tion of the procedures performed not onlyaffects payment but is integral to internalmanagement systems, external perfor-mance comparisons and the assessmentof quality of care. The detail and complete-ness of ICD-10-PCS is essential in today’shealth care environment.

Communications with Physicians

ICD-9-CM procedure codes often pro-vide a relatively poor description of theprecise procedure performed. Thus, physi-cians reviewing or analyzing data coded inICD-9-CM can have difficulty developingclinical pathways, evaluating the codingfrom a fraud and abuse perspective or per-forming research. The ICD-10-PCS codesprovide a more clinically relevant descrip-tion of procedures that can be morereadily understood and used by physi-cians.

Conclusion

ICD-10-PCS has been developed as areplacement for Volume 3 of ICD-9-CM.The system has evolved during its fiveyear development based on extensiveinput from many segments of the healthcare industry. The multi-axial structure ofthe system combined with its detailed defi-nition of all terminology will permit a pre-cise specification of procedures for use inhealth services research, epidemiology,statistical analysis and administrativeareas. It will also enhance the ability ofhealth information coders to determineaccurate procedure codes with minimaleffort.


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 tubeControl 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 bleedingControl 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 disarticulationBelow knee amputatio

Documents

Development of the ICD-10 Procedure Coding System (ICD-10-PCS) · 2018. 2. 16. · ICD-10-PCS was under devel-opment for over five years and the initial draft was formally tested