ICD-10 PCS Self ReviewPrepared by: Maria Kuch

Resources:2016 ICD-10 PCS Coder Training Manual AHIMA

Comprehensive Medical Coding : Lorraine Papazian - Boyce

2016 The Official ICD-10 PCS Code Book

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7 CHARACTERS

Character 1:SECTION

Character 2: BODY SYSTEM

Character 3: ROOT OPERATION

Character 4: BODY PART

Character 5: APPROACH

Character 6: DEVICE

Character 7: QUALIFIER

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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

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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.

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Character 2: BODY SYSTEM for Skeletal

N Head & Facial Bones

P Upper Bones

Q Lower Bones

R Upper Joints

S Lower Joints

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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 : SECTION

K Muscle : BODY SYSTEM

9 Drainage: ROOT OPERATION

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TABLE LIST OF ROOT OPERATION - Examples

ROOT OPERATIONWHAT

OPERATION DOESOBJECTIVES OF PROCEDURES

PROCEDURE SITE EXAMPLE

Excision Takes out some/all of the body

Cutting out/off without

replacement

Some of the body part

Breast Lumpectomy

DrainageTakes out solids/fluids/gases from

body

Taking/letting out fluids/gases

Within the body part Incision & drainage

Division Involved cutting or separation only

Cutting into/separating a body

part

Within 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/animal

Some/all of a body part Kidney Transplant

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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 Extremities

In BODY PART it could be LEFT FOOT

Central Nervous = Trigeminal Nerve

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Character 5 APPROACHAPPROACH 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.

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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)

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Components of Approachcontinue..

Method - specifies how the external access location is entered.

OPEN method = Cutting through the skin or mucous membrane

TYPE OF INSTRUMENTATION - refers to the specialized equipment used to perform the procedure.

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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 OPENING

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

VIA 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

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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

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