Mary Jo Bowie MS, BS, AAS, RHIA, RHIT

Medical and Surgical Section CHAPTER 28 Medical and Surgical Section

Medical and Surgical Section The first section within ICD-10-PCS is the Medical and Surgical section. The character 1 value for the Medical and Surgical section is 0. The majority of procedures in this section are completed in an inpatient setting.

Characters and Their Meanings within the Medical and Surgical Section Character 2—Body System. There are 31 body systems for the Medical and Surgical section. Character 3—Root Operations. There are 31 different root operations for this section. Character 4—Body Part. The body part indicates the specific part of the body system on which the procedure was performed.

Characters and Their Meanings (cont.) Character 5—Approach. This character identifies the technique used to reach the site of the procedure. Character 6—Device. This character is used only to specify devices that remain after the procedure is completed. Character 7—Qualifier. This character contains unique values for individual procedures.

Body System- Character 2 Represents the general body system of the root operation. Example of values 0-Central Nervous system 1- Peripheral Nervous system 2- Heart and Great Vessels

Root Operations—Character 3 The root operation identifies the objective of the procedure. Each root operation has a precise definition. The definitions are listed in the Introduction of the ICD-10-PCS Manual.

Body Part—Character 4 The body part should not be confused with the body system. The body system identifies the body system in which the procedure is completed, character 2, and the body part identifies the specific part of the body system on which the procedure was performed.

Tubular Body Parts ICD-10-PCS defined tubular body parts as hollow body parts that provide a route of passage for solids, liquids, or gases. Example of tubular body parts are: Intestines Esophagus Arteries

Approach—Character 5 There a seven different approaches: Open Percutaneous Percutaneous endoscopic

Approaches (cont.) Via natural or artificial opening Via natural or artificial opening endoscopic Via natural or artificial opening with percutaneous endoscopic assistance External

Approach Components Access Location Method Type of Instrumentation skin or mucous membranes external orifices Method Open instrumentation Type of Instrumentation

Character 6—Device Character 6 reports devices that remain after the procedure is completed, such as: Grafts and Prostheses Implants Simple or Mechanical Appliances Electronic Appliances

Character 7—Qualifiers Qualifiers are unique values for individual procedures and therefore have different meanings in the various Tables. When no qualifier is present, the character value is Z.

Key Points to Remember The Medical and Surgical section of ICD-10-PCS contains the majority of the codes used in ICD-10-PCS. There are seven characters within a code. To locate a code, start with the Index.

Additional Points Coders must have an understanding of the root operations as defined in the Introduction to ICD-10-PCS. The root operation is based on the objective of the procedure. The root operation character is assigned based on the procedure actually performed.

Final Points The approach of the procedure must also be identified for proper code selection. Devices that remain within the body are identified with character 6. The Tables must be reviewed to select the value for character 7, as these characters are unique to each table.

Coding Guidelines The coding guidelines address the following: Conventions Body System General guidelines Root operations Multiple procedures Discontinued procedures

Coding Guidelines Continued Root operations Biopsy followed by more definitive treatment Overlapping body layers Bypass procedures Control vs. more definitive root operations Excision vs. Resection Excision for graft Fusion procedures of the spine Inspection procedures

Coding Guidelines Continued Root operations Occlusion vs. Restriction for vessel embolization procedures Release procedures Release vs. Division Reposition for fracture treatment Transplantation vs. Administration

Coding Guidelines Continued Body Part General guidelines Branches of body parts Bilateral body part values Coronary arteries Tendons, ligaments, bursae and fascia near a joint Skin, subcutaneous tissue and fascia overlying a joint Fingers and toes

Coding Guidelines Continued Device General Guidelines Drainage device

Coding Practice Select the code for the following: Open repair of abdominal wall

Coding Practice Solution Main term to reference in index: Repair Modifying term: Abdominal Wall Code Assignment: 0WQF0ZZ