ICD-10 PCSPrepared by: Maria Kuch

7 CHARACTERSCharacter 1:SECTION

Character 2: BODY SYSTEM

Character 3: ROOT OPERATION

Character 4: BODY PART

Character 5: APPROACH

Character 6: DEVICE

Character 7: QUALIFIER

CHARACTERS Definition

Character 1:SECTION - is defined as the broad procedure category where the code is found. Or the general type of procedure.

EXAMPLE: The Medical and Surgical SECTION is found under “0” value.

0 Medical and Surgical

2 Heart and Great Vessel

7 Dilation

Character 2: BODY SYSTEM

Body System is defined in which the procedure is performed or the anatomical region where the procedure is performed, such as central nervous system or skeletal system.

Example:

0 - SECTION

N - HEAD & FACIAL BONES

Note Skeletal System is divided in 5 body system

Head & facial bones, upper bones, lower bones, upper joint etc.

Character 2: BODY SYSTEM for Skeletal

N Head & Facial Bones

P Upper BonesQ Lower BonesR Upper JointsS Lower Joints

Character 3: ROOT OPERATION

ROOT Operation is defined as the 3rd character and describe the objective of the procedure such as excision, destruction, etc.Example:0 Medical and Surgical : SECTIONK Muscle : BODY SYSTEM9 Drainage: ROOT OPERATION

TABLE LIST OF ROOT OPERATION - Examples

ROOT OPERATION

WHAT OPERATION

DOESOBJECTIVES OF PROCEDURES PROCEDURE SITE EXAMPLE

ExcisionTakes out

some/all of the body

Cutting out/off without

replacementSome of the body

partBreast

Lumpectomy

DrainageTakes out

solids/fluids/gases from body

Taking/letting out fluids/gases

Within the body part

Incision & drainage

DivisionInvolved cutting

or separation only

Cutting into/separating a

body partWithin the body

part Neurotomy

Transplantation

Puts in/puts back or moves some

all of a body part

Putting in a living body part from a

person/animalSome/all of a

body partKidney

Transplant

Character 4: BODY PART

BODY PART defines the specific anatomical site where the procedure is performed.Body part may specify laterality.Example:BODY SYSTEM - Lower ExtremitiesIn BODY PART it could be LEFT FOOTCentral Nervous = Trigeminal Nerve

Character 5 APPROACH

APPROACH is defines as the technique used to reach the site of the procedure such as open, endoscopic, or external.There are 7 different approaches. The Approach is comprised of 3 components: the access location, method, & type of instrumentation.ACCES LOCATION - specifies the external site through which the procedure is reached.

3 Components of Approach

ACCES LOCATION - specifies the external site through which the procedure is reached.

There are 2 general type of access locations: SKIN or MUCOUS membranes and external orifices.

Skin or mucous can be cut or punctured to reach the procedure site, OPEN & PERCUTANEOUS approach values use this access location. External opening which can be natural (mouth) or artificial (colostomy)

Components of Approachcontinue..

Method - specifies how the external access location is entered. OPEN method = Cutting through the skin or mucous membraneTYPE OF INSTRUMENTATION - refers to the specialized equipment used to perform the procedure.

APPROACH DefinitionOPEN Cutting through the skin or mucous membrane & any other

body layers necessary to expose the site of the procedure

PERCUTANEOUSEntry, by puncture or minor incision, of instrumentation through the skin or

mucous membrane &/or any other body layers necessary to reach the site of the procedure

PERCUTANEOUS ENDOSCOPIC

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

visualize the site of the procedure.VIA NATURAL OR

ARTIFICIAL OPENINGEntry of instrumentation through natural or artificial external

opening to reach the site of the procedureVIA NATURAL OR

ARTIFICIAL OPENING ENDOSCOPIC

Entry of instrumentation through natural or artificial external opening to reach and visualize the site of the procedure

VIA NATUAL OR ARTIFICIAL OPENING

ENDOSCOPIC W/PERCUTANEOUS

ENDOSCOPIC ASSISTANCE

Entry of instrumentation through a natural or artificial opening to reach & visualize the site of the procedure, & entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane & any other body layers necessary to aid in

the performance of the procedure

EXTERNALProcedure performed directly on the skin or mucous membrane and procedures

performed indirectly by the application of external force through the skin or mucous membrane

APPROACH VALUES0 Open

3 Percutaneous

4 Percutaneous Endoscopic

7 Via Natural or Artificial Opening

8 Via Natural or Artificial Opening Endoscopic

F Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance

X External