1. ICD-10-PCS Boot Camp Presented by: Karen Kvarfordt, RHIA, CCS-P, CCDS
President, DiagnosisPlus, Inc.
2014

3. Things will never be the same once we switch to ICD-10-PCS!
Complete overhaul of the procedure classification system as we know it today.
Tip! Refer to Appendix F: Character Meanings – this will save you!
But don’t panic, it can be easily mastered!

4. More Tips…
ICD-10-PCS codes include one digit for the root operation that the physician performs.
Root operation is always the 3rd character in the seven character code.
Start by reviewing the definitions of the various root operations. If you learn the root operations early, you’ll have a head start on learning how to code in ICD-10- PCS.

5. And The Best Tip!
Always look first in the Alphabetic Index (will give you the first 3 or 4 characters) and then finish building the procedure code in the Tables.
Key! You can’t jump around in the tables. Need to go across to get your procedure code!

6. Who Developed The ICD-10-PCS System?
CMS awarded the contract to 3M Health Information Systems to develop a new procedure coding system for ICD-10.
New system is intended to replace ICD- 9-CM Volume 3 for reporting hospital inpatient procedures.
But what about the outpatient side?

7. General Principles
Diagnostic information is not included in the code description.
A ‘not elsewhere classified’ option is allowed for new devices and substances.
All substantially different procedures are defined.

8. General Principles “Limited NOS” Option
A general body part, approach, or root operation can be used when the level of specificity is not available in the record or cannot otherwise be obtained.
Should you query?

9. Limited NOS Option Body Part: Approach: Root Operation:
Example: “Liver” is used when the specific liver lobe is not identified.
Approach:
“Open”, “Percutaneous” and “Via Natural or Artificial Opening” are used when a more specific type of approach is not documented and cannot otherwise be determined.
Root Operation:
“Repair” is used when the procedure documentation does NOT support a specific root operation and the information cannot otherwise be obtained.

10. ICD-9-CM vs. ICD-10-PCS ICD-9-CM (Volume 3) (Procedures) ICD-10-PCS
Min. characters: 3
Max. characters: 4
Numeric format
(+ V code)
Decimal point
3,000 procedure codes
ICD-10-PCS
(Procedures)
Min. characters: 7
Max. characters: 7
Alphanumeric format
No decimal point
71,918 procedure codes

11. Number of Codes in ICD-10-PCS
Section
Codes
Medical and Surgical**
61,896
Obstetrics
300
Placement
861
Administration
1,384
Measurement and Monitoring
339
Extracorporeal Assistance and Performance 41
Extracorporeal Therapies 42
Osteopathic
100
Other Procedures 60
Chiropractic 90
Imaging
2,934
Nuclear Medicine
463
Radiation Oncology
1,939
Rehabilitation and Diagnostic Audiology
1,380
Mental Health 30
Substance Abuse Treatment 59
Total
71,918

12. ICD-10-PCS: Code Structure
Seven Character Alphanumeric Code
All procedure codes will be seven characters long
“I” and “O” (letters) are never used
Why not?
34 possible values for each character
Digits 0 – 9
Letters A-H, J-N, P-Z

13. System Structure 16 Sections
Medical and Surgical
Other Procedures
Obstetrics
Chiropractic
Placement
Imaging
Administration
Nuclear Medicine
Measurement and Monitoring
Radiation Oncology
Extracorporeal Assistance and Performance
Physical Rehabilitation and Diagnostic Audiology
Extracorporeal Therapies
Mental Health
Osteopathic
Substance Abuse Treatment

14. ICD-10-PCS Tables
Each table contains four columns and varying numbers of rows.
Column: Specifies the allowable values for characters 4-7
Row: Specifies the valid combinations of values
Building block concept!

16. ICD-10-PCS Characters
Section: Identifies general type of procedure Body System: Identifies general body system Root Operation: Specifies objective of procedure Body Part: Identifies specific part of body system on which procedure is being performed Approach: Technique used to reach the site of the procedure Device: Identifies devices that remain after procedure is completed Qualifier: Provides additional information about a procedure, if necessary

17. ICD-10-PCS Index
Provides the first three or four characters of the procedure code.
The tables must always be used to obtain the remaining digits for the complete code.
No eponyms are included.
Tables are used to construct a complete and valid code.
Only characters appearing on the table may be used.

18. Medical and Surgical Section

19. ICD-10-PCS Characters (Medical and Surgical Section)
Root
Section Operation Approach Qualifier
Body Body Device
System Part

20. Susie Buys Root Beer At Dairy Queen
1st character = Section
2nd character = Body System
3rd character = Root Operation
4th character = Body Part
5th character = Approach
6th character = Device
7th character = Qualifier

21. Medical and Surgical Section Principles
The root operation is based on the “objective or intent” of the procedure not by the procedure name.
If multiple procedures as defined by distinct objectives are performed, then multiple ICD-10-PCS procedure codes are assigned.

22. Section Character (Character 1)
16 sections within ICD-10-PCS, the largest being the Medical & Surgical section.
Defines the general ‘type’ of procedure, i.e., Med/Surg, OB, etc.
Medical and Surgical Section the first character is always the number “0”.

23. Body System Character (Character 2)
Identifies the body system, which is the general physiological system or anatomical region where the procedure is performed.
Total of 31 body systems in ICD-10-PCS.
Some traditional categories are subdivided into several body systems, for example:
Cardiovascular is subdivided into 5 body systems:
Heart and Great Vessels
Upper Arteries
Lower Arteries
Upper Veins
Lower Veins

24. Body Systems
Refer to the ICD-10-PCS code book for a complete listing of the body systems (pg. 5).

25. Root Operation Character (Character 3)
Defines the “objective” or “intent” of doing the procedure.
33 different root operation values
Each root operation identifies a precise and distinct objective.
This is the most difficult part of procedural coding as the root operations may sound familiar, but may mean different things.
Most time will be spent here!

26. Where Will The Confusion Be?
The root operations ‘excision’ and ‘resection’ will be the most difficult to distinguish.
Excision: Cutting out or off, without replacement a portion of a body part
Resection: Cutting out or off, without replacement, all of a body part
These definitions look very similar, but are very different as they involve a portion versus all of a body part.

27. Root Operations Alteration Fragmentation Restriction Bypass Excision
Release
Change
Extirpation
Removal
Control
Extraction
Repair
Creation
Replacement
Destruction
Fusion
Reposition
Detachment
Insertion
Resection
Dilation
Inspection
Division
Map
Revision
Drainage
Occlusion
Supplement
Reattachment
Transfer
Transplantation

28. Look at Procedures in a Whole New Way
In ICD-10-PCS, every procedure falls into one of 33 root operations, which define the ‘objective’ of the procedure.
Some root operations seem self-explanatory, i.e., transplantation or reattachment, others are not so easy.
Procedure documentation may often include the term “removal”, but according to PCS definitions the physician actually performed an extraction or even an extirpation, Do not code directly what the physician lists as the procedure; rather, you should always read the OP report to determine what the physician actually did and which definition the procedure meets.

29. Potential Documentation Problem
Procedure: Nonexcisional debridement of skin and back. There is no term in ICD-10-PCS for “debridement”, so based on definitions, the coder must review the body of the OP report to see what the physician actually performed. In this case, code the debridement as an extraction because it fits the definition (i.e., being pulled off a portion of the body part by use of force). In this case, skin is the body part.

30. Root Operation Principles
The root operation is coded according to the objective of the procedure actually performed.
Discontinued or modified procedures coded to procedure actually performed.
Composite terms (i.e., colonoscopy, sigmoidectomy) are not root operations.
Combination procedures are coded separately
Each procedure with a distinct objective during an operative episode is coded separately.

31. More Principles
The complete or partial redo of a procedure is coded to the root operation performed rather than “revision”.
Revision is confined to correcting a malfunctioning or displaced device
New for ICD-10

32. Root Operation Groups
Procedures that take out or eliminate all or a portion of a body part
Procedures that involve putting in or on, putting back, or moving body parts
Procedures that take out or eliminate solid matter, fluids, or gases from a body part
Procedures that only involve examination of body parts and regions
Procedures that can be performed only on tubular body parts
Procedures that always involve devices
Procedures involving cutting or separation only
Procedures involving other repairs
Procedures with other objectives

33. Root Operations (1st Group)
Procedures that take out or eliminate all or a portion of a body part
Excision
Resection
Extraction
Destruction
Detachment

34. Excision
Definition: Cutting out or off, without replacement, a portion of a body part
Explanation: The qualifier Diagnostic is used to identify excision procedures that are biopsies
Examples:
Partial nephrectomy
Liver Biopsy

35. Resection
Definition: Cutting out or off, without replacement, all of a body part
Examples:
Total nephrectomy
Total lobectomy of lung

36. Extraction
Definition: Pulling or stripping out or off all or a portion of a body part by the use of force
Explanation: The qualifier Diagnostic is used to identify extraction procedures that are biopsies
Examples:
Dilatation and curettage
Vein stripping

37. Destruction
Definition: Physical eradication of all or a portion of a body part by the direct use of energy, force or a destructive agent
Explanation: None of the body part is physically taken out
Examples:
Fulguration of rectal polyp
Cautery of skin lesion

38. Detachment
Definition: Cutting off all or part of the upper or lower extremities
Explanation: The body part value is the site of the detachment, with a qualifier if applicable, to further specify the level where the extremity was detached
Examples:
Below knee amputation
Disarticulation of shoulder

39. Root Operations (2nd Group)
Procedures that involve putting in or on, putting back, or moving living body parts
Transplantation
Reattachment
Reposition
Transfer

40. Transplantation
Definition: 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
Explanation: The native body part may or may not be taken out, and the transplanted body part may take over all or a portion of its function
Examples:
Kidney transplant
Heart transplant

41. Reattachment
Definition: Putting back in or on all or a portion of a separated body part to its normal location or other suitable location
Explanation: Vascular circulation and nervous pathways may or may not be reestablished
Examples:
Reattachment of hand
Reattachment of avulsed kidney

42. Reposition
Definition: Moving to its normal location or other suitable location all or a portion of a body part
Explanation: The body part is moved to a new location from an abnormal location, or from a normal location where it is not functioning correctly. The body part may or may not be cut out or off to be moved to the new location
Examples:
Reposition of undescended testicles
Fracture reduction

43. Transfer
Definition: Moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part
Explanation: The body part transferred remains connected to its vascular and nervous supply
Examples:
Tendon transfer
Skin pedicle flap transfer

44. Root Operations (3rd Group)
Procedures that take out or eliminate solid matter, fluids or gases from a body part
Drainage
Extirpation (new term in ICD-10)
Fragmentation

45. Drainage
Definition: Taking or letting out fluids and/or gases from a body part
Explanation: The qualifier Diagnostic is used to identify drainage procedures that are biopsies
Examples:
Thoracentesis
Incision and drainage (I&D)

46. Extirpation
Definition: Taking or cutting out solid matter from a body part
Explanation: The solid matter may be an abnormal byproduct of a biological function or a foreign body. The solid matter is imbedded in a body part, or is in the lumen of a tubular body part. The solid matter may or may not have been previously broken into pieces. No appreciable amount of the body part is taken out
Examples:
Thrombectomy
Choledocholithotomy

47. Fragmentation
Definition: Breaking solid matter in a body part into pieces
Explanation: The solid matter may be an abnormal byproduct of a biological function or a foreign body. Physical force, i.e. manual, ultrasonic, applied directly or indirectly through intervening body parts is used to break the solid matter into pieces. The pieces of solid matter are not taken out, but are eliminated or absorbed through normal biological functions
Example: Extracorporeal shockwave lithotripsy

48. Root Operations (4th Group)
Procedures that only involve examination of body parts and regions
Inspection
Map

49. Inspection Definition: Visually and/or manually exploring a body part
Explanation: Visual exploration may be performed with or without optical instrumentation. Manual exploration may be performed directly or through intervening body layers
Examples:
Diagnostic arthroscopy
Exploratory laparotomy

50. Map
Definition: Locating the route of passage of electrical impulses and/or locating functional areas in a body part
Explanation: Applicable only to the cardiac conduction mechanism and the central nervous system
Examples:
Cardiac mapping
Cortical mapping

51. Root Operations (5th Group)
Procedures that can be performed only on tubular body parts
Bypass
Dilation
Occlusion
Restriction

52. 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 (downstream) area in the normal route; rerouting the contents to another different but similar route and body part; or to an abnormal route and another dissimilar body part. It includes one or more concurrent anastomoses with or without the use of a device such as autografts, tissue substitutes and synthetic substitutes
Examples:
Coronary artery bypass
Colostomy formation

53. Dilation
Definition: Expanding an orifice or the lumen of a tubular body part
Explanation: The orifice can be a natural orifice or an artificially created orifice. Accomplished by stretching a tubular body part using intraluminal pressure or by cutting part of the orifice or wall of the tubular body part
Examples:
Percutaneous transluminal angioplasty
Pyloromyotomy

54. Occlusion
Definition: Completely closing the orifice or lumen of a tubular body part
Explanation: The orifice can be a natural orifice or an artificially created orifice
Examples:
Fallopian tube ligation
Ligation of inferior vena cava

55. Restriction
Definition: Partially closing the orifice or lumen of a tubular body part
Explanation: The orifice can be a natural orifice or an artificially created orifice
Example:
Esophagogastric fundoplication

56. Root Operations (6th Group)
Procedures that always involve devices
Insertion
Replacement
Supplement
Removal
Change Revision

57. Insertion
Definition: Putting in a nonbiological appliance that monitors, assists, performs or prevents a physiological function but does not physically take the place of a body part
Examples:
Insertion of radioactive implant
Insertion of central venous catheter

58. Replacement
Definition: Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part
Explanation: The biological material is non-living, or the biological material is living and from the same individual. The body part may have been previously taken out, previously replaces, or may be taken out concomitantly with the replacement procedure. If the body part has been previously replaced, a separate Removal procedure is coded for taking out the device used in the previous replacement
Example: Total knee/hip replacement

59. Total Knee Replacement in ICD-10-PCS
Right Knee Joint Replacement ICD-9-CM: (Total Knee Replacement) S R D J Z
Section
(Medical/Surgical)
Body System
(Lower Joints)
Root Operation
(Replacement)
Body Part
(Knee Joint, Right)
Approach
(Open)
Device
(Synthetic Substitute)
Qualifier
(No Qualifier)

60. Supplement
Definition: Putting in or on biological or synthetic material that physically reinforces or augments the function of a body part
Explanation: The biological material in non-living, or the material is living and from the same individual. The body part may have been previously replaced. If the body part has been previously replaced, the Supplement procedure is performed to physically reinforce and/or augment the function of the replaced body part
Examples:
Herniorrhaphy using mesh
New acetabular liner in a previous hip replacement

61. Removal Definition: Taking out or off a device from a body part
Explanation: If the device is taken out and a similar device is put in without cutting or puncturing the skin or mucous membrane, the procedure is coded to the root operation Change. Otherwise, the procedure for taking out the device is coded to the root operation Removal and the procedure for putting in the new device is coded to the root operation as performed
Examples: Drainage tube removal
Cardiac pacemaker removal

62. 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: All Change procedures are coded using the approach External
Examples:
Urinary catheter change
Gastrostomy tube change

63. Revision
Definition: Correcting, to the extent possible, a malfunctioning or displaced device
Explanation: Revision can include correcting a malfunctioning or displaced device by taking out or putting in components of the device such as a screw
Examples:
Adjustment of pacemaker lead
Adjustment of hip prosthesis

64. Root Operations (7th Group)
Procedures involving cutting or separation only
Division
Release

65. Division
Definition: Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part
Explanation: All or a portion of the body part is separated into two or more portions
Examples:
Spinal cordotomy
Osteotomy

66. Release
Definition: Freeing a body part from an abnormal physical constraint by cutting or by use of force
Explanation: Some of the restraining tissue may be taken out but none of the body part is taken out
Examples:
Adhesiolysis
Carpal tunnel release

67. Root Operations (8th Group)
Procedures involving other repairs
Control
Repair

68. Control
Definition: Stopping, or attempting to stop, post-procedure bleeding
Explanation: The site of the bleeding is coded as an anatomical region and not to a specific body part
Examples:
Control of post-prostatectomy hemorrhage
Control of post-tonsillectomy hemorrhage

69. Repair
Definition: Restoring, to the extent possible, a body part to its normal anatomic structure and function
Explanation: Used only when the method to accomplish the repair is not one of the other root operation (used as ‘default’)
Examples:
Herniorrhaphy
Suture of laceration

70. Root Operations (9th Group)
Procedures with other objectives
Alteration
Creation
Fusion

71. Alteration
Definition: Modifying the 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

72. Creation
Definition: Making a new genital structure that does not take over the function of a body part
Explanation: Used only for sex change operations
Examples:
Creation of vagina in a male
Creation of penis in a female

73. Fusion
Definition: Joining together portions of an articular body part rendering the articular body part immobile
Explanation: The body part is joined together by fixation device, bone graft, or other means
Examples:
Spinal fusion
Ankle arthrodesis

74. Body Part Character (Character 4)
Identifies the body part or specific anatomical site where the physician performed a procedure
34 possible body part values in each body system
Hepatobiliary
Liver
Liver, Right Lobe
Liver, Left Lobe
Gallbladder
Hepatic Duct, Right
Hepatic Duct, Left

75. Approach Character (Character 5)
Indicates the technique the physician used to reach the site of the procedure.
Approaches may be through the skin or mucous membranes, through an orifice, or external.
ICD-10-PCS will have 7 different approach values.

76. Different Approaches…
Approaches through the skin or mucous membrane
Open (Abdominal hysterectomy)
Percutaneous (Needle biopsy of liver)
Percutaneous Endoscopic (Arthroscopy)

77. Approaches through an orifice
Via Natural or Artificial Opening (Endotracheal intubation)
Via Natural or Artificial Opening Endoscopic (Sigmoidoscopy)
Via Natural or Artificial Opening Endoscopic with Percutaneous Endoscopic Assistance (Lap-assisted vaginal hysterectomy)

78. Final Approach…External
Procedures performed directly on the skin or mucous membrane and procedures performed indirectly by the application of ‘external’ force through the skin or mucous membrane
Example: Closed fracture reduction

79. Device Character (Character 6)
The term “device” includes only those devices that remain after the procedure is completed.
Instruments that describe how a procedure is performed are not specified in the device character.
Instruments for visualization are specified in the approach character, i.e., scope, etc.
Materials that are incidental to a procedure (i.e., clips, sutures) are not considered devices and would use device character “Z” to indicate “no device” in the ICD-10-PCS code.

80. Device Values Four (4) Categories Of Devices:
Grafts and Prostheses
Implants
Simple or Mechanical Appliances
Electronic Appliance
Some of the devices used in musculoskeletal system procedures are internal and external fixation devices, bone growth stimulators, and drainage devices.

81. Device Categories
Biological or synthetic material that takes the place of all or a portion of a body part (i.e., skin graft, joint prosthesis).
Biological or synthetic material that assists or prevents a physiological function (i.e. urinary catheter, IUD).
Therapeutic material that is not absorbed by, eliminated by, or incorporated into a body part (i.e. radioactive implant, orthopedic pins). Therapeutic materials that are considered devices can be removed.

82. Mechanical or electronic appliances used to assist, monitor, take the place of, or prevent a physiological function (i.e., diaphragmatic pacemaker, hearing device).

83. Examples of Device Values
Drainage Device
Radioactive Element
Autologous Tissue Substitute
Extraluminal Device
Intraluminal Device
Synthetic Substitute
Nonautologous Tissue Substitute

84. Last But Not Least… Qualifier!
Defines an additional attribute of the procedure performed, if applicable.
May have a narrow application, to a specific root operation, body system, or body part.
Examples of Qualifiers
Type of transplant
Second site for a bypass
Diagnostic excision (biopsy)

85. Coding Example
CHIEF COMPLAINT: Foreign body in nose. HISTORY OF PRESENT ILLNESS: The patient is a 3-year-old child who comes in today after having put a raisin in her left nostril while playing at home. Grandmother was unable to remove it. EMERGENCY DEPARTMENT COURSE: The raisin was grasped by bayonet forceps and removed atraumatically. Examination of the nostril fails to reveal any further foreign body or problems. DIAGNOSIS: Foreign body in nostril with removal.

86. Coding Example ICD-10-CM (Diagnosis)
ICD-9-CM: 932 (Foreign body in nose)
ICD-10-CM: 2 options which contain more specific information about anatomic site and encounter.
T170xxA = Foreign body in nasal sinus, initial encounter
T171xxA = Foreign body in nostril, initial encounter

87. Coding Example ICD-10-PCS (Procedure)
ICD-9-CM: (Removal of intraluminal foreign body from nose without incision)
ICD-10-PCS: Only 1 translation and/or coding option
09CKXZZ = Extirpation of matter from nose, external approach

88. That’s ICD-10-PCS!

89. Let’s Practice What We Have Learned!

90. Resources

91. THANKS A TON! Day Egusquiza, President daylee1@mindspring.com
Karen Kvarfordt, RHIA, CCS-P, CCDS
AHIMA Certified ICD-10 Trainer
President, DiagnosisPlus, Inc.