1. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. 17-1 Chapter 17 ICD-10-PCS MEDICAL AND SURGICAL SECTION (0)

2. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Learning Objectives LO 17.1 Recognize the seven components of an ICD-10-PCS code. LO 17.2 Interpret the procedure to determine the accurate root operation term. LO 17.3 Utilize knowledge of anatomy to determine the body part treated. 17-2

3. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Learning Objectives (cont.) LO 17.4 Identify the approach used to access the body part. LO 17.5 Distinguish the type of device implanted, when applicable. LO 17.6 Select the appropriate qualifier character. 17-3

4. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Key Terms Approach Character Root operation 17-4

5. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Introduction Medical and surgical procedures, services, and treatments are reported with codes from this first section of the tables of ICD- 10-PCS Codes are subdivided by anatomical site or organ system that is the focus of the procedure 17-5

6. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Definitions Each character position has a meaning Each section uses each character position differently Medical and Surgical section characters: 17-6

7. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 1: Medical and Surgical Section 0 (Zero) –All codes reporting a medical or surgical procedure will begin with a zero 17-7

8. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 2: Body System: 0–9, B–Y –0 Central Nervous System –1 Peripheral Nervous System –2 Heart and Great Vessels –3 Upper Arteries –4 Lower Arteries –5 Upper Veins 17-8

9. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 2: Body System: 0–9, B–Y (cont.) –6 Lower Veins –7 Lymphatic and Hemic Systems –8 Eye –9 Ear, Nose, Sinus –B Respiratory System –C Mouth and Throat 17-9

10. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 2: Body System: 0–9, B–Y (cont.) –D Gastrointestinal System –F Hepatobiliary System and Pancreas –G Endocrine System –H Skin and Breast –J Subcutaneous Tissue and Fascia –K Muscles 17-10

11. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 2: Body System: 0–9, B–Y (cont.) –L Tendons –M Bursae and Ligaments –N Head and Facial Bones –P Upper Bones –Q Lower Bones –R Upper Joints –S Lower Joints 17-11

12. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 2: Body System: 0–9, B–Y (cont.) –T Urinary System –U Female Reproductive System –V Male Reproductive System –W Anatomical Regions, General –X Anatomical Regions, Upper Extremities –Y Anatomical Regions, Lower Extremities 17-12

13. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 2: Body System: 0–9, B–Y (cont.) There is a 0 (zero) and a number 1 (one) but no letter O or letter I Body system characters W, X, and Y reporting anatomical regions should be used only when the procedure was performed on an anatomical cavity rather than an individual body part 17-13

14. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. 31 root operation terms describe what procedure was performed for the patient during this encounter –Alteration: Modification of a natural anatomic structure of a body part without affecting the function of the body part... Character 0 (zero) 17-14 Character Position 3: Root Operation

15. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. –Bypass: Changing the route of a tubular body part’s contents and how it passes through the body... Character 1 –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... Character 2 17-15 Character Position 3: Root Operation

16. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 3: Root Operation (cont.) –Control: Stopping, or attempting to stop, post procedural bleeding... Character 3 –Creation: Creating a new genital structure that does not take over the function of a body part... Character: 4 For example: sex change operations 17-16

17. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 3: Root Operation (cont.) –Destruction: Physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent without replacement... Character: 5 –Detachment: Cutting of all or a portion of the upper or lower extremities... Character 6 For example: amputation 17-17

18. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 3: Root Operation (cont.) –Dilation: Expanding an orifice or the lumen of a tubular body part... Character 7 –Division: Cutting into a body part in order to separate or transect a body part (without draining fluids and/or gases from the body part)... Character 8 17-18

19. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 3: Root Operation (cont.) –Drainage: Taking or letting out fluids and/or gases from a body part... Character 9 –Excision: Cutting out or off, without replacement a portion of a body part... Character B For example: biopsy 17-19

20. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 3: Root Operation (cont.) –Extirpation: Taking or cutting out solid matter from a body part...Character C –Extraction: Pulling or stripping out or off all or a portion of a body part by the use of force... Character D 17-20

21. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 3: Root Operation (cont.) –Fragmentation: Breaking solid matter in a body part into pieces... Character F –Fusion: Joining together portions of an articular body part rendering the articular body part immobile... Character G 17-21

22. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 3: Root Operation (cont.) –Insertion: Putting in non biological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part... Character H –Inspection: Visually and/or manually exploring a body part... Character J 17-22

23. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 3: Root Operation (cont.) –Map: Locating the route of passage of electrical impulses and/or locating functional areas in a body part... Character K –Occlusion: Completing closing an orifice or lumen of a tubular body part... Character L 17-23

24. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 3: Root Operation (cont.) –Reattachment: Putting back in or on all or a portion of a separated body part to its normal location or other suitable location... Character M –Release: Freeing a body part from an abnormal physical constraint by cutting or by use of force... Character N 17-24

25. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 3: Root Operation (cont.) –Removal: Taking out or off a device from a body part... Character P –Repair: Restoring, to the extent possible, a body part to its normal anatomic structure and function... Character Q 17-25

26. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 3: Root Operation (cont.) –Replacement: 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... Character R –Reposition: Moving to its normal location or other suitable location all or a portion of a body part... Character S 17-26

27. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 3: Root Operation (cont.) –Resection: Cutting out or off, without replacement, all of a body part... Character T –Restriction: Partially closing an orifice or lumen of a tubular body part... Character V 17-27

28. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 3: Root Operation (cont.) –Revision: Correcting, to the extent possible, a portion of a malfunctioning device or the position of a displaced device... Character W –Supplement: Putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part... Character U 17-28

29. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 3: Root Operation (cont.) –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... Character X –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...Character Y 17-29

30. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 4: Body Part: 0–9,B–Y This character will identify the specific body part that is the focus of the procedure Bilateral procedures –If the documentation identifies that a procedure was performed on both a right body part and a left body part –Two codes used when no code character available 17-30

31. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 4: Body Part: 0–9,B–Y (cont.) Coronary arteries –Represented by one code character, but there are additional characters to report when more than one site is treated in this one set of arteries 17-31

32. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 4: Body Part: 0–9,B–Y (cont.) Joints and muscles –Shoulder is reported as Upper Arm –Elbow is reported as Lower Arm –Wrist is reported as Lower Arm –Hip is reported as Upper Leg 17-32

33. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 4: Body Part: 0–9,B–Y (cont.) Joints and muscles (cont.) –Knee is reported as Lower Leg –Ankle is reported as Foot –Finger is reported as Hand –Toe is reported as Foot 17-33

34. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 4: Body Part: 0–9,B–Y (cont.) Gastrointestinal body system –Upper Intestinal Tract includes esophagus, stomach, to and including the duodenum –Lower Intestinal Tract includes jejunum, ileus, cecum, large intestine, including the anus 17-34

35. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 4: Body Part: 0–9,B–Y (cont.) Body Part Key Appendix –Helps when a specific anatomical site is documented and the Body Part components are not as specific 17-35

36. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 5: Approach First four characters explain what the physician did and the anatomical site upon which he or she worked The fifth character explains how the physician got to the anatomical site to perform the procedure 17-36

37. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 5: Approach (cont.) Open: Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure... Character 0 17-37

38. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 5: Approach (cont.) 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 procedure... Character 3 17-38

39. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 5: Approach (cont.) 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 procedure... Character 4 17-39

40. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 5: Approach (cont.) Via Natural or Artificial Opening: Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure... Character 7 17-40

41. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 5: Approach (cont.) Via Natural or Artificial Opening Endoscopic: Entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure... Character 8 17-41

42. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 5: Approach (cont.) External: Procedure performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane... Character X 17-42

43. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 6: Device Identifies a device that will remain with the patient after the procedure has been completed 17-43

44. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 6: Device Grafts –Autologous tissue substitute... Character 7 –Autologous venous tissue... Character 9 –Autologous arterial tissue... Character A –Synthetic substitute... Character J –Nonautologous tissue substitute... Character K –Zooplastic tissue... Character 8 17-44

45. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 6: Device (cont.) Simple or Mechanical Appliances –Drainage device... Character 0 –Monitoring device... Character 2 Monitoring device, pressure sensor... Character 0 –Infusion device... Character 3 17-45

46. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 6: Device (cont.) Simple or Mechanical Appliances (cont.) –Extraluminal device... Character C –Intraluminal device... Character D Drug-eluting intraluminal device... Character 4 Bioactive intraluminal device... Character B Radioactive intraluminal device... Character T 17-46

47. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 6: Device (cont.) Implants and Electronic Appliances –Stimulator (cardiac) lead... Character M –Cardiac lead, defibrillator... Character K –Cardiac lead, pacemaker... Character J –Implantable heart assist system... Character Q –External heart assist system... Character R –Radioactive element... Character 1 –No device... Character Z 17-47

48. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 7: Qualifier Seventh character is required In many cases, there may be no more details to add, so you will use the placeholder Z No Qualifier—the equivalent of “not applicable” 17-48

49. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 7: Qualifier (cont.) Multiple Procedures –More than one procedure does not necessarily mean you will report more than one code The same root operation is performed on different body parts as defined by distinct values of the body part character The same root operation is repeated at different body sites that are included in the same body part value Multiple root operations with distinct objectives are performed on the same body part 17-49

50. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Character Position 7: Qualifier (cont.) Multiple Procedures (cont.) –The intended root operation is attempted using one approach but is converted to a different approach Discontinued Procedures –Report root operations that were actually done 17-50

51. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Chapter Summary Building a code in ICD-10-PCS may require you to become familiar with a different perspective and way of interpreting the physician’s notes. 17-51