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

2. Medical and Surgical Section
CHAPTER 28
Medical and Surgical Section

3. 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.

4. 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.

5. 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.

6. 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

7. 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.

8. 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.

9. 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

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

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

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

13. 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

14. 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.

15. 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.

16. 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.

17. 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.

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

19. 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

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

21. 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

22. Coding Guidelines Continued
Device
General Guidelines
Drainage device

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

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