ICD-10-Procedure 

Coding System

(ICD-10-PCS)


Development Background

..CMS awarded a contract to 3M Health 
Information Systems to develop a new 
procedure coding system 
..The new system is intended to replace 
ICD-9-CM Volume 3 for reporting 
inpatient procedures



Development History

1995 -1996: First draft of ICD-10-PCS completed 

1996 -1997: Training program developed 

Informal testing conducted 

ICD-10-PCS revised 

1997 -1998: Independent formal testing conducted 

ICD-10-PCS revised 
Final draft completed 

1998-presentICD-10-PCS updated annually


Major Development Goals

..Improve accuracy and efficiency of coding
..Reduce training effort
..Improve communication with physicians



Essential Attributes

..Completeness
All substantially different procedures have a 
unique code
..Expandability
The structure of the system allows 
incorporation of new procedures as unique 
codes



Essential Attributes

Standardized terminology

Includes definitions of the terminology used. 
..While the meaning of specific words can vary in 
common usage, ICD-10-PCS defines a single 
meaning for each term used in the system. 



Essential Attributes

Multiaxial

The system has a multiaxialstructure. 


Each character has the same meaning 
within a section and across sections to the 
extent possible


General Principles

..Diagnostic information is not included in 
the code description
..A not elsewhere classifiedoption is 
allowed for new devices and substances
..All substantially different procedures are 
defined



General Principles 

Limited NOS Option

A general body part, approach, or root 
operation can be used when the level of 
specificity required is not available in the 
record or cannot otherwise be obtained


Text Box: General Principles Limited NOS Option
Code Structure

..Codes are comprised of seven components. 
Each component is called a character
All codes are seven characters long
..Individual units for each character are 
represented by a letter or number 
Each unit is called a value
..34 possible values for each character
Digits 0-9
Letters A-H, J-N, P-Z



System Structure 

16 Sections

Text Box: Medical and Surgical
Obstetrics
Placement
Administration
Measurement and Monitoring
Extracorporeal Assistance and Performance
Extracorporeal Therapies
Osteopathic
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


0: Medical and Surgical Section 
D Gastrointestinal System 
B: EXCISION: Cutting out or off, without replacement, a portion of a body part. 
Body Part Approach Device Qualifier 
1 Esophagus, Upper 
2 Esophagus, Middle 
3 Esophagus, Lower 
4 EsophagogastricJunction 
5 Esophagus 
6 Stomach 
7 Stomach, Pylorus 
8 Small Intestine 
9 Duodenum 
A Jejunum 
B Ileum 
C Ileocecal Valve 
E Large Intestine 
F Large Intestine, Right 
G Large Intestine, Left 
H Cecum 
J Appendix 
K Ascending Colon 
L Transverse Colon 
M Descending Colon 
N Sigmoid Colon 
P Rectum 
0 Open 
2 Open Endoscopic 
3 Percutaneous 
4 Percutaneous Endoscopic 
7 Via Natural or Artificial Opening 
8 Via Natural or Artificial Opening 
Endoscopic 
Z No Device X Diagnostic 
Z No Qualifier 
Q Anus 0 Open 
2 Open Endoscopic 
3 Percutaneous 
4 Percutaneous Endoscopic 
7 Via Natural or Artificial Opening 
8 Via Natural or Artificial Opening 
Endoscopic 
X External 
Z No Device X Diagnostic 
Z No Qualifier 
R Anal Sphincter 
S Greater Omentum 
T Lesser Omentum 
V Mesentery 
W Peritoneum 
0 Open 
3 Percutaneous 
4 Percutaneous Endoscopic 
Z No Device X Diagnostic 
Z No Qualifier 

ICD-10-PCS Index

..Provides the first three or four values of 
the code
..The tables must always be used to obtain 
the complete code
..No eponyms are included



Index Conventions

..Main index term is a root operation, root procedure 
type, or common procedure name


Examples:Resection (root operation)

Fluoroscopy (root type)

Prostatectomy (common procedure name)

..Secondary entries are specific to the main term
Body system 
Body part
Device



Index Entry by Root Operation

Bypass

by Body System 

.

Gastrointestinal System 0D1 .

Heart and Great Vessels 021.

Hepatobiliaryand Pancreas 0F1 .

Lower Arteries 041 .

Lower Veins 061 .


Index Entry by Body Part

Bypass

by Body Part

Artery

Aorta, Abdominal 0410

Aorta, Thoracic 021W

Axillary 031

Brachial 031

Common Carotid 031


Medical and Surgical 
Section


Medical and Surgical Section

Character Specification

11223344556677SectionSectionBody SystemBody SystemRoot OperationRoot OperationApproachApproachDeviceDeviceQualifierQualifierBody Part/RegionBody Part/Region

Medical and Surgical Section 
Principles 

..The root operation is based on the objective 
of the procedure


..If multiple procedures as defined by distinct 
objectives are performed, then multiple 
codes are assigned



Medical and Surgical Section 
Principles

..Root Operation 
Value is consistent throughout the section
..Approach
Value is consistent throughout the section
..Body part
Value is consistent within a specific body 
system



Section Character

Medical and Surgical Section


Section 

(Character 1)

..Defines the general type of procedure


..In the Medical and Surgical Section the 
first character is always the number 0



Body System Character

Medical and Surgical Section


Body System 

(Character 2)

..Defines the general physiological system on which the 
procedure is performed, or anatomical region where the 
procedure is performed
..Uses generally accepted anatomical or physiological 
categories 
..Some traditional categories are subdivided into several 
body systems. 
Cardiovascular is subdivided into five body systems:


Heart and Great VesselsUpper Veins 

Upper Arteries Lower Veins

Lower Arteries 


Medical and Surgical Section

Body Systems

Central Nervous

Peripheral Nervous

Heart and Great Vessels

Upper Arteries

Lower Arteries

Upper Veins

Lower Veins

Lymphatic and Hemic

Eye

Ear, Nose, Sinus

Respiratory

Mouth and Throat

Gastrointestinal

Hepatobiliaryand Pancreas

Endocrine

Skin and Breast

Subcutaneous Tissue and Fascia

Muscles

Tendons

Bursaeand Ligaments

Head and Facial Bones

Upper Bones 

Lower Bones

Upper Joints

Lower Joints

Urinary

Female Reproductive

Male Reproductive

Anatomical Regions, General

Anatomical Regions, Upper Extremities

Anatomical Regions, Lower Extremities


Root Operation 

Character

Medical and Surgical Section


Medical and Surgical Section

Root Operation 

(Character 3) 

..Defines the objective of the procedure
..30 different root operation values
Each root operation identifies a precise 
and distinct objective



Medical and Surgical Section 

Root Operations

Alteration Excision Release 
Bypass Extirpation Removal 
Change Extraction Repair 
Control Fragmentation Replacement 
Creation Fusion Reposition 
Destruction Insertion Resection 
Detachment Inspection Restriction 
Dilation Map Revision 
Division Occlusion Transfer 
Drainage Reattachment Transplantation 

Medical and Surgical Section

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 (e.g., colonoscopy, 
sigmoidectomy) are not root operations



Medical and Surgical Section

Root Operation Principles

..Combination procedures are coded 
separately
Each procedure with a distinct objective during 
an operative episode is coded separately
..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



Medical and Surgical Section 

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



Medical and Surgical Section 

Root Operation Groups

..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



Medical and Surgical Section

Root Operations

Procedures that take out or eliminate 

all or a portion of a body part

Excision
Resection
Extraction
Destruction
Detachment



Medical and Surgical Section 

Root Operations 

Excision

DefinitionCutting out or off, without 
replacement, a portion of a body part

ExplanationThe qualifier Diagnosticis used to 
identify excision procedures that are 
biopsies

ExamplesPartial nephrectomyLiver biopsy


Medical and Surgical Section

Root Operations 

Resection

DefinitionCutting out or off, without replacement, 
all of a body part

ExamplesTotal nephrectomyTotal lobectomy of lung


Medical and Surgical Section

Root Operations 

Extraction

DefinitionPulling or stripping out or off, by use of force, 
all or a portion of a body part

ExplanationThe body part is pulled or stripped from its 
location by the use of force (e.g. manual, 
suction). The qualifier Diagnosticis used 
to identify extraction procedures that are 
biopsies

ExamplesDilation and curettageVein stripping


Medical and Surgical Section

Root Operations 

Destruction

DefinitionEradicating all or a portion of a body part

ExplanationUsed for the actual physical destruction of all 
or a portion of a body part by the direct use of 
energy, force or a destructive agent. 
None of the body part is taken out

ExamplesFulguration of rectal polypCauteryof skin lesion


Medical and Surgical Section

Root Operations 

Detachment

..DefinitionCutting off all or a portion of 
an extremity 
..Explanation Cutting off all or part of the 
upper or lower extremities 
..ExamplesBelow knee amputation 
Disarticulation of shoulder



Medical and Surgical Section

Root Operations

Procedures that involve putting in or on, putting 
back, or moving living body parts

Transplantation 
Reattachment
Reposition
Transfer



Medical and Surgical Section

Root Operations 

Transplantation

DefinitionPutting 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

ExplanationThe 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

ExamplesLung transplantHeart transplant


Medical and Surgical Section 

Root Operations 

Reattachment

DefinitionPutting back in or on all or a portion of a 
separated body part to its normal location or 
other suitable location

ExplanationVascular circulation and nervous pathways 
may or may not be reestablished

ExamplesReattachment of handReattachment of avulsed kidney


Medical and Surgical Section

Root Operations 

Reposition

DefinitionMoving to its normal location or other suitable 
location all or a portion of a body part

ExplanationThe body part is moved to a new location from 
an aberrant 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

ExamplesReposition of undescendedtesticleFracture reduction


Medical and Surgical Section

Root Operations 

Transfer

DefinitionMoving, 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

ExplanationThe body part transferred remains connected to 
its vascular and nervous supply

ExamplesTendon transfer

Skin pedicle flap transfer


Medical and Surgical Section 

Root Operations

Procedures that take out or eliminate 

solid matter, fluids or gases from a body part 

Drainage
Extirpation
Fragmentation



Medical and Surgical Section

Root Operations 

Drainage

DefinitionTaking or letting out fluids and/or 
gases from a body part

ExplanationThe qualifier Diagnosticis used to 
identify drainage procedures that are 
biopsies 

ExamplesThoracentesisIncision and drainage


Medical and Surgical Section

Root Operations 

Extirpation

DefinitionTaking or cutting out solid matter from a body 
part

ExplanationThe 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

ExamplesThrombectomyCholedocholithotomy


Medical and Surgical Section

Root Operations 

Fragmentation

DefinitionBreaking down solid matter in a body part

ExplanationThe solid matter may be an abnormal byproduct 
of a biological function or a foreign body. 
Physical force (e.g., 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

ExamplesExtracorporeal shockwave lithotripsy 
Transurethral lithotripsy


Medical and Surgical Section

Root Operations

Procedures that only involve examination 
of body parts and regions

Inspection
Map



Medical and Surgical Section

Root Operations 

Inspection

DefinitionVisually and/or manually exploring a 
body part

ExplanationVisual exploration may be performed 
with or without optical instrumentation. 
Manual exploration may be performed 
directly or through intervening body 
layers

ExamplesDiagnostic arthroscopyExploratory laparotomy


Medical and Surgical Section

Root Operations 

Map

DefinitionLocating the route of passage of 
electrical impulses and/or locating 
functional areas in a body part

ExplanationApplicable only to the cardiac 
conduction mechanism and the central 
nervous system

ExamplesCardiac mapping 
Cortical mapping


Medical and Surgical Section

Root Operations

Procedures that can be performed only on 
tubular body parts

Bypass
Dilation
Occlusion
Restriction



Medical and Surgical Section

Root Operations 

Bypass

DefinitionAltering the route of passage of the contents of a tubular 
body part

ExplanationRerouting 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 
anastomoseswith or without the use of a device such as 
autografts, tissue substitutes and synthetic substitutes

ExamplesCoronary artery bypass 
Colostomy formation


Medical and Surgical Section

Root Operations 

Dilation

DefinitionExpanding an orifice or the lumen of a tubular 
body part

ExplanationThe 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

ExamplesPercutaneous transluminal angioplastyPyloromyotomy


Medical and Surgical Section

Root Operations 

Occlusion

DefinitionCompletely closing the orifice or lumen of a 
tubular body part

ExplanationThe orifice can be a natural orifice or an 
artificially created orifice

ExampleFallopian tube ligationLigationof inferior vena cava


Medical and Surgical Section

Root Operations 

Restriction

DefinitionPartially closing the orifice or lumen of a 
tubular body part

ExplanationThe orifice can be a natural orifice or an 
artificially created orifice

Examples EsophagogastricfundoplicationCervical cerclage


Medical and Surgical Section

Root Operations

Procedures that always involve devices

Insertion
Replacement
Removal
Change
Revision



Medical and Surgical Section

Root Operations 

Insertion

DefinitionPutting in a nonbiological appliance that 
monitors, assists, performs or prevents a 
physiological function but does not 
physically take the place of a body part

ExamplesInsertion of radioactive implant 
Insertion of central venous catheter


Medical and Surgical Section

Root Operations 

Replacement

DefinitionPutting in or on biological or synthetic material 
that physically takes the place of all or a portion 
of a body part

ExplanationThe 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 replaced, or may 
be taken out concomitantly with the Replacement 
procedure

ExamplesTotal hip replacementFree skin graft


Medical and Surgical Section 

Root Operations 

Removal

DefinitionTaking out or off a device from a body part

ExplanationIf taking out a device and putting in a similar 
device is performed with an external approach, 
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 performed

ExamplesDrainage tube removal 
Cardiac pacemaker removal


Medical and Surgical Section

Root Operations 

Change

DefinitionTaking 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

ExamplesUrinary catheter change 
Gastrostomytube change


Medical and Surgical Section

Root Operation 

Revision

DefinitionCorrecting, to the extent possible, a 
malfunctioning or displaced device

ExamplesAdjustment of pacemaker lead 
Adjustment of hip prosthesis


Medical and Surgical Section

Root Operations

Procedures involving cutting or separation 
only

Division
Release



Medical and Surgical Section

Root Operations 

Division

DefinitionSeparating, without taking out, a body 
part

ExplanationAll or a portion of the body part is 
separated into two or more portions

ExamplesSpinal cordotomy, osteotomy


Medical and Surgical Section

Root Operations 

Release

DefinitionFreeing a body part

ExplanationEliminating an abnormal constraint of a body 
part by cutting or by use of force. Some of 
the restraining tissue may be taken out but 
none of the body part is taken out

ExamplesAdhesiolysisCarpal tunnel release


Medical and Surgical Section

Root Operations

Procedures involving other repairs

Control
Repair



Medical and Surgical Section

Root Operations 

Control

DefinitionStopping, or attempting to stop, 
post-procedure bleeding

ExplanationThe site of the bleeding is coded as ananatomical region and not to a specific 
body part

ExamplesControl of post-prostatectomy 
hemorrhage 
Control of post-tonsillectomy hemorrhage


Medical and Surgical Section

Root Operations

Repair

DefinitionRestoring, to the extent possible, a body 
part to its normal anatomic structure and 
function

ExplanationUsed only when the method to 
accomplish the repair is not one of the 
other root operations

ExamplesHerniorrhaphySuture of laceration


Medical and Surgical Section

Root Operations

Procedures with other objectives

Alteration
Creation
Fusion



Medical and Surgical Section

Root Operations 

Alteration

DefinitionModifying the anatomical 
structure of a body part without 
affecting the function of the body part

ExplanationPrincipal purpose is to improve 
appearance

ExamplesFace lift 
Breast augmentation


Medical and Surgical Section

Root Operations 

Creation

DefinitionMaking a new structure that does not 
physically take the place of a body part

ExplanationConfined to sex change operations where 
genitalia are made

ExamplesCreation of vagina in a male 
Creation of penis in a female


Medical and Surgical Section

Root Operations 

Fusion

DefinitionJoining together portions of an articularbody part rendering the articularbody 
part immobile

ExamplesSpinal fusionAnkle arthrodesis


Body Part Character

Medical and Surgical Section 


Medical and Surgical Section

Body Part Character

(Character 4)

..Defines the specific anatomical site where the 
procedure is performed
..34 possible body part values in each body system



Medical and Surgical Section

Body Part Values 

Hepatobiliaryand Pancreas

Liver

Liver, Right Lobe

Liver, Left Lobe

Liver, Caudate Lobe

Gallbladder

Hepatic Duct, Right

Hepatic Duct, Left

Hepatic Duct, Caudate

Cystic Duct

Common Bile Duct

Ampullaof Vater

Pancreatic Duct

Pancreatic Duct, Accessory

Pancreas


Approach Character

Medical and Surgical Section 


Medical and Surgical Section

Approach 

(Character 5)

..Defines the technique used to reach the site of 
the procedure
..8 different approach values



Medical and Surgical Section

Approach

Approaches through the skin or mucous 
membrane 

Open
Open Endoscopic
Open with Percutaneous Endoscopic 
Assistance
Percutaneous
Percutaneous Endoscopic



Medical and Surgical Section

Approach Definitions

OPEN

Cutting through the skin or mucous 
membrane and any other body layers 
necessary to expose the site of the 
procedure

Example:Abdominal hysterectomy


Medical and Surgical Section

Approach Definitions

OPEN ENDOSCOPIC

Cutting through the skin or mucous membrane and 
any other body layers necessary to expose a body 
part, and introduction of instrumentation to reach 
and visualize the site of the procedure

Example:Open colonoscopy with polypectomy


Medical and Surgical Section

Approach Definitions

OPEN WITH PERCUTANEOUS 

ENDOSCOPIC ASSISTANCE

Cutting through the skin or mucous membrane and 
any other body layers necessary to expose the site of 
the procedure, and entry, by puncture or minor 
incision, of instrumentation through the skin or 
mucous membrane and any other body layers 
necessary to aid in the performance of the procedure

Example:Laparoscopic-assisted vaginal 
hysterectomy


Medical and Surgical Section

Approach Definitions

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

Example:Needle biopsy of liver


Medical and Surgical Section

Approach Definitions

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

Example:Arthroscopy


Medical and Surgical Section

Approach

Approaches through an orifice

..Via Natural or Artificial Opening
..Via Natural or Artificial Opening 
Endoscopic



Medical and Surgical Section

Approach Definitions

VIA NATURAL OR ARTIFICIAL OPENING

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

Example:Endotrachealintubation


Medical and Surgical Section

Approach Definitions

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

Example:Sigmoidoscopy


Medical and Surgical Section

Approach Definitions 

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


Device Character

Medical and Surgical Section


Medical and Surgical Section

Device Character

(Character 6)

..The term deviceincludes only 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
..Materials incidental to a procedure such as clips 
and sutures are not considered devices



Medical and Surgical Section

Device Categories

..Biological or synthetic material that takes the place 
of all or a portion of a body part (e.g., skin graft, 
joint prosthesis)
..Biological or synthetic material that assists or 
prevents a physiological function (e.g., urinary 
catheter, IUD)



Medical and Surgical Section

Device Categories

..Therapeutic material that is not absorbed by, 
eliminated by, or incorporated into a body part (e.g., 
radioactive implant, orthopedic pins). Therapeutic 
materials that are considered devices can be removed
..Mechanical or electronic appliances used to assist, 
monitor, take the place of, or prevent a physiological 
function (e.g., diaphragmatic pacemaker, hearing 
device)



Medical and Surgical Section 

Examples of Device Values

..Drainage Device
..Radioactive Element
..AutologousTissue 
Substitute
..ExtraluminalDevice
..IntraluminalDevice
..Synthetic Substitute
..NonautologousTissue Substitute



Qualifier

Medical and Surgical Section


Medical and Surgical Section 

Qualifier 

(Character 7)

..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



Medical and Surgical Section 

Examples of Qualifiers

..Type of transplant
..Second site for a bypass
..Diagnostic excision (biopsy)



0: Medical and Surgical Section 
D Gastrointestinal System 
B: EXCISION: Cutting out or off, without replacement, a portion of a body part. 
Body Part Approach Device Qualifier 
1 Esophagus, Upper 
2 Esophagus, Middle 
3 Esophagus, Lower 
4 EsophagogastricJunction 
5 Esophagus 
6 Stomach 
7 Stomach, Pylorus 
8 Small Intestine 
9 Duodenum 
A Jejunum 
B Ileum 
C Ileocecal Valve 
E Large Intestine 
F Large Intestine, Right 
G Large Intestine, Left 
H Cecum 
J Appendix 
K Ascending Colon 
L Transverse Colon 
M Descending Colon 
N Sigmoid Colon 
P Rectum 
0 Open 
2 Open Endoscopic 
3 Percutaneous 
4 Percutaneous Endoscopic 
7 Via Natural or Artificial Opening 
8 Via Natural or Artificial Opening 
Endoscopic 
Z No Device X Diagnostic 
Z No Qualifier 
Q Anus 0 Open 
2 Open Endoscopic 
3 Percutaneous 
4 Percutaneous Endoscopic 
7 Via Natural or Artificial Opening 
8 Via Natural or Artificial Opening 
Endoscopic 
X External 
Z No Device X Diagnostic 
Z No Qualifier 
R Anal Sphincter 
S Greater Omentum 
T Lesser Omentum 
V Mesentery 
W Peritoneum 
0 Open 
3 Percutaneous 
4 Percutaneous Endoscopic 
Z No Device X Diagnostic 
Z No Qualifier 

Obstetrics Section


Obstetrics SectionObstetrics SectionCharacter SpecificationCharacter Specification
11223344556677SectionSectionBody SystemBody SystemRoot OperationRoot OperationApproachApproachDeviceDeviceQualifierQualifierBody PartBody Part

..Includes only procedures performed on the 
products of conception
..Operations on the pregnant female are coded in 
the Medical and Surgical section (e.g., 
episiotomy)
..Two root operations unique to this section
..Other root operations same as Medical and 
Surgical section (e.g., Drainage, Inspection)


Obstetrics SectionObstetrics Section


Obstetrics Section 

Body System

(Character 2)

Contains a single body system:

Pregnancy



Abortion: Artificially terminating a pregnancy

Delivery:Assisting the passage of the products of 
conception from the genital canal

Obstetrics Section 

Root Operation

(Character 3)


Obstetrics Section 

Body Part

(Character 4)

Contains three different values for body part

Products of Conception
Products of Conception, Retained
Products of Conception, Ectopic



..Products of conception refers to all components of 
a pregnancy, including the fetus, embryo, amnion, 
umbilical cord and placenta
..There is no differentiation of the products of 
conception based on gestational age


Obstetrics Section Obstetrics Section 

Body PartBody Part


Obstetrics Section 

Device

(Character 6)

Some device values unique to this section

Examples:

Laminaria

Abortifacient

Monitoring Electrode


Obstetrics Section 

Qualifier

(Character 7)

Values are dependent on the root operation, 
approach, or body part 

Examples (root operation dependent):

Method of extraction (e.g., low forceps, 
vacuum)

Substance drained (e.g., amniotic fluid, fetal 
blood)


Obstetrics Section Table

1: OBSTETRICS 
0: PREGNANCY 
Q: REPAIR: Restoring, to the extent possible, a body part to its normal anatomical structure and function 
Body Part 
Character 4 
Approach 
Character 5 
Device 
Character 6 
Qualifier 
Character 7 
0 Products of Conception 
0 Open 
2 Open Endoscopic 
3 Percutaneous 
4 Percutaneous 
Endoscopic 
7 Via Natural or Artificial 
Opening 
8 Via Natural or Artificial 
Opening Endoscopic 
Y Other Device 
Z No Device 
E Nervous System 
F Cardiovascular System 
G Lymphatics & Hemic 
H Eye 
J Ear, Nose & Sinus 
K Respiratory System 
L Mouth & Throat 
M Gastrointestinal System 
N Hepatobiliary & Pancreas 
P Endocrine System 
Q Skin 
R Musculoskeletal System 
S Urinary System 
T Female Reproductive System 
V Male Reproductive System 
Y Other Body System 

Placement Section


Placement Section

Character Specification

11223344556677SectionSectionBody SystemBody SystemRoot OperationRoot OperationApproachApproachDeviceDeviceQualifierQualifierBody Region/OrificeBody Region/Orifice

Placement Section 

Body System 

(Character 2)

Contains two body system values:

Anatomical Regions
Anatomical Orifices



Placement Section 

Root Operation

(Character 3)

..Five root operations unique to this section
Compression
Dressing
Immobilization
Packing
Traction
..Two root operations common to other sections
Change
Removal



Placement Section 

Root Operation

(Character 3)

Compression:Putting pressure on a body region

Dressing:Putting material on a body region for 
protection

Immobilization:Limiting or preventing motion of 
a body region

Packing:Putting material in a body region or 
orifice

Traction:Exerting a pulling force on a body 
region in a distal direction


Placement Section 

Body Regions/Orifices

(Character 4)

..Two types of values: 
External body regions (e.g., chest wall)
Natural orifices (e.g., mouth and pharynx)



Placement Section

Device 

(Character 6)

..Specifies the material or device in the placement procedure 
(e.g., splint, bandage)
..Includes casts for fractures and dislocations
..Devices in the placement section are off the shelf and do 
not require any extensive design, fabrication or fitting
..The placement of devices that require extensive design, 
fabrication or fitting are coded in the Rehabilitation section



Placement Section

Table

2: PLACEMENT 
Y: ANATOMICAL ORIFICES 
4: PACKING: Putting material in a body region or orifice 
Body Region 
Character 4 
Approach 
Character 5 
Device 
Character 6 
Qualifier 
Character 7 
0 Mouth and Pharynx 
1 Nasal 
2 Ear 
3 Anorectal 
4 Female Genital Tract 
5 Urethra 
X External 
5 Packing Material Z No Qualifier 

Administration 
Section


Administration Section

Character Specification

11223344556677SectionSectionPhysiological SystemPhysiological SystemRoot OperationRoot OperationApproachApproachSubstanceSubstanceQualifierQualifierBody System/Body System/
RegionRegion

Administration Section

Body System

(Character 2)

Contains three body system values:

Physiological Systems and Anatomical Regions
Circulatory
Indwelling Device



Administration Section 

Root Operation

(Character 3)

Physiological Systems and Anatomical Regions

Introduction:Putting in a therapeutic, diagnostic, 
nutritional, physiological or 
prophylactic substance except blood 
or blood products

Irrigation:Putting in or on a cleansing 
substance


Administration Section 

Root Operation

(Character 3)

Circulatory System

Transfusion:Putting in blood or blood 
products


Administration Section 

Root Operation

(Character 3)

Indwelling Device

Irrigation:Putting in or on a cleansing 
substance


Administration Section 

Body Part

(Character 4)

..For Introduction, the body part specifies where the 
procedure occurs and not necessarily the site 
where the substance introduced has an effect
..For Irrigation, the body part specifies the site of 
the irrigation



Administration Section 

Approach

(Character 5)

..Approach uses values defined in the Medical and Surgical 
section
..The approach value for intradermal, subcutaneous and 
intramuscular introductions (i.e., injections) is 
percutaneous
..If a catheter is used to introduce a substance into a site 
within the circulatory system, the approach value is also 
percutaneous



Administration Section

Substance

(Character 6)

..Substances are specified in broad 
categories
..Substance values depend on body part



Administration Section 

Substance

Physiological System & Anatomical Regions

Antineoplastic

Thrombolytic

Anti-infective

Anti-inflammatory

Radioactive Substance

Nutritional Substance

Electrolytic and 

Water Balance Substance

Irrigating Substance

Dialysate

Local Anesthetic

Regional Anesthetic

Inhalation Anesthetic

Gas

Contrast Agent

Fertilized Ovum

Sperm

Pigment

Platelet Inhibitor

Destructive Agent

Examples:


Text Box: White Cells
Platelets
Globulin
Fibrinogen
Factor IX
Bone Marrow
Administration Section 

Qualifier

(Character 7)

..May further specify a substance
..Examples:
High-dose Interleukin-2
Liquid BrachytherapyIsotope
Insulin



Administration Section 

Table

3: ADMINISTRATION 
0: CIRCULATORY 
2: TRANSFUSION: Putting in blood or blood products 
Body System 
Character 4 
Approach 
Character 5 
Substance 
Character 6 
Qualifier 
Character 7 
3 Peripheral Vein 
4 Central Vein 
0 Open 
3 Percutaneous 
G Bone Marrow 
H Whole Blood 
J Serum Albumin 
K Frozen Plasma 
L Fresh Plasma 
M Plasma 
Cryoprecipitate 
N Red Blood Cells 
P Frozen Red Cells 
Q White Cells 
R Platelets 
S Globulin 
T Fibrinogen 
V Antihemophilic 
Factors 
W Factor IX 
X Stem Cells, Cord 
Blood 
Y Stem Cells, 
Hematpoietic 
0 Autologous 
1 Nonautologous 

Measurement and 
Monitoring Section


Measurement and Monitoring

Character Specification

11223344556677SectionSectionPhysiological SystemPhysiological SystemRoot OperationRoot OperationApproachApproachFunctionFunctionQualifierQualifierBody SystemBody System

Measurement and Monitoring 

Body System

(Character 2)

Contains a single body system value:

Physiological Systems



Measurement and Monitoring 

Root Operation

(Character 3)

..Measurement:Determining the level of a 
physiological or physical 
function at a point in time
..Monitoring:Determining the level of a 
physiological or physical 
function repetitively over a 
period of time



Measurement and Monitoring 

Approach

(Character 5)

Approach contains values also in the 
Medical and Surgical section

Examples:

Percutaneous

Via Natural or Artificial Opening 
Endoscopic


Measurement and Monitoring 

Function

(Character 6)

Specifies physiological or physical 
functions (e.g., nerve conductivity, cardiac 
electrical activity, respiratory capacity)


Measurement and Monitoring

Table

4: MEASUREMENT AND MONITORING 
A: PHYSIOLOGICAL SYSTEMS 
1: MONITORING: Determining the level of a physiological or physical function repetitively over a period 
of time 
Body System 
Character 4 
Approach 
Character 5 
Function 
Character 6 
Qualifier 
Character 7 
0 Central Nervous 
0 Open 
2 Conductivity 
4 Electrical Activity 
B Pressure 
Z No Qualifier 
0 Central Nervous 3 Percutaneous 
7 Via Natural or Artificial 
Opening 
B Pressure 
K Temperature 
R Saturation 
D Intracranial 
0 Central Nervous X External 2 Conductivity 
4 Electrical Activity 
Z No Qualifier 

Extracorporeal 
Assistance and 
Performance Section


Extracorporeal Assistance 

and Performance

Character Specification

11223344556677SectionSectionPhysiological SystemPhysiological SystemRoot OperationRoot OperationDurationDurationFunctionFunctionQualifierQualifierBody SystemBody System

Extracorporeal Assistance 

and Performance

Body System

(Character 2)

Contains a single body system value:

..Physiological Systems



Extracorporeal Assistance 

and Performance

Root Operation

(Character 3)

Assistance: Taking over a portion of a physiological 
function by extracorporeal means

Performance: Completely taking over a physiological 
function by extracorporeal means

Restoration:Returning, or attempting to return, a 
physiological function to its normal 
state by extracorporeal means


Extracorporeal Assistance 

and Performance

Duration

(Character 5)

..Specifies whether the procedure was a single 
occurrence, multiple occurrence, intermittent, or 
continuous


..For respiratory ventilation assistance or 
performance, the range of hours is specified 


(<24 hours, 24-96 hours or >96 hours)


Extracorporeal Assistance 

and Performance

Function

(Character 6)

Specifies the physiological function 
assisted or performed (e.g., oxygenation, 
ventilation)


Extracorporeal Assistance 

and Performance 

Qualifier

(Character 7)

May specify equipment used in the 
procedure (e.g., balloon pump)


Extracorporeal Assistance 

and Performance 

Table

5: EXTRACORPOREAL ASSISTANCE AND PERFORMANCE 
A: PHYSIOLOGICAL SYSTEMS 
2: RESTORATION: Returning, or attempting to return, a physiological function to its original state by 
extracorporeal means. 
Body System 
Character 4 
Duration 
Character 5 
Function 
Character 6 
Qualifier 
Character 7 
2 Cardiac 
0 Single 
4 Rhythm Z No Qualifier 

Extracorporeal 

Therapies 

Section


Extracorporeal Therapies

Character Specification

11223344556677SectionSectionPhysiological SystemPhysiological SystemRoot OperationRoot OperationDurationDurationQualifierQualifierQualifierQualifierBody SystemBody System

Extracorporeal Therapies 

Body System

(Character 2)

Contains a single body system value:

..Physiological Systems



Extracorporeal Therapies 

Root Operation

(Character 3)

Contains ten root operation values:

Atmospheric ControlPheresis

DecompressionPhototherapy

Electromagnetic TherapyUltrasound Therapy

Hyperthermia Ultraviolet Light 

HypothermiaTherapy

Shock Wave Therapy


Extracorporeal Therapies 

Duration 

(Character 5)

Specifies whether the procedure was a 
single occurrence, multiple occurrence, 
or intermittent


Osteopathic Section


Osteopathic Section

Character Specification

11223344556677SectionSectionAnatomical RegionsAnatomical RegionsRoot OperationRoot OperationApproachApproachMethodMethodQualifierQualifierBody RegionBody Region

Osteopathic Section 

Body System

(Character 2)

Contains a single body system value:

Anatomical Regions



Osteopathic Section 

Root Operation

(Character 3)

Contains a single root operation value

Treatment: 

..Manual treatment to eliminate or alleviate 
somatic dysfunction and related disorders



Osteopathic Section 

Method

(Character 6)

..Articulatory-Raising
..FascialRelease
..General Mobilization
..High Velocity -Low Amplitude
..Indirect
..Low Velocity-High Amplitude
..Lymphatic Pump
..Muscle Energy -Isometric
..Muscle Energy -Isotonic
..Other Method



Other Procedures 
Section


Other Procedures Section

Character Specification

11223344556677SectionSectionAnatomical Anatomical 
RegionsRegionsRoot OperationRoot OperationApproachApproachMethodMethodQualifierQualifierBody RegionBody Region

Other Procedures Section

Root Operation

(Character 3)

Contains a single root operation value

Other Procedures:

Methodologies which attempt to 
remediate or cure a disorder or disease



Other Procedures Section

Body Region

(Character 4)

Contains six body region values:

Whole Body
Nervous System
IntegumentarySystem and Breast
Male Reproductive
Female Reproductive
None



Miscellaneous Section

Method

(Character 6)

..Acupuncture
..Therapeutic Massage
..Yoga Therapy
..Meditation
..Fertilization


..Isolation
..Collection
..Examination
..Suture Removal
..Piercing



Chiropractic Section


Chiropractic Section

Character Specification

11223344556677SectionSectionAnatomical RegionsAnatomical RegionsRoot OperationRoot OperationApproachApproachMethodMethodQualifierQualifierBody RegionBody Region

Chiropractic Section 

Body System

(Character 2)

Contains a single body system value:

Anatomical Regions



Chiropractic Section

Root Operation

(Character 3)

Contains a single root operation value

Manipulation:

Manual procedure that involves a 
directed thrust to move a joint past the 
physiological range of motion, without 
exceeding the anatomical limit



Chiropractic Section 

Method

(Character 6)

..Non-Manual
..Indirect Visceral
..Extra-Articular
..Direct Visceral
..Long Lever Specific Contact
..Long and Short Lever Specific Contact
..Mechanically Assisted
..Other Method



Imaging Section


Imaging Section

Character Specification

1234567SectionBody SystemTypeContrastQualifierQualifierBody Part

Imaging Section

..Contains diagnostic radiology procedures
Nuclear medicine is a separate section 
Radiation Oncology is a separate section
Interventional Radiology
..The intervention procedure is coded in the Medical 
and Surgical section



Imaging Section

Root Type 

(Character 3)

..Plain Radiography
..Fluoroscopy
..CT Scan
..MRI
..Ultrasound



Imaging Section

Root Type Definitions

(Character 3)


Imaging Section 

Root Type

Plain Radiography

Planar display of an image developed 
from the capture of external ionizing 
radiation on photographic or 
photoconductive plate


ImagingSection

Root Type

Fluoroscopy

Single plane or bi-plane real time display 
of an image developed from the capture of 
external ionizing radiation on a 
fluorescent screen. The image may also 
be stored by either digital or analog means


Imaging Section

Root Type 

Computerized Tomography 

(CT Scan)

Computer-reformatted digital display of 
multiplanarimages developed from the 
capture of multiple exposures of external 
ionizing radiation


Imaging Section

RootType 

Magnetic Resonance Imaging 

(MRI)

Computer-reformatted digital display of 
multiplanarimages developed from the 
capture of radio-frequency signals emitted 
by nuclei in a body site excited within a 
magnetic field


Imaging Section

Root Type 

Ultrasonography

Real time display of images of anatomy or flow 
information developed from the capture of 
reflected and attenuated high frequency sound 
waves


Imaging Section

Contrast Material 

(Character 5)

..Contrast is differentiated by the 
concentration of the contrast material 
(e.g., high or low osmolar)



Imaging Section 

Qualifier

(Character 6)

..Specifies an imaging procedure without 
contrast followed by contrast



Nuclear Medicine 
Section


Nuclear Medicine Section

Character Specification

11223344556677SectionSectionBody SystemBody SystemRadionuclideRadionuclideQualifierQualifierQualifierQualifierTypeTypeBody PartBody Part

Nuclear Medicine Section 

Type Definitions

(Character 3)


Nuclear Medicine

Root Type 

Planar Imaging

Introduction of radioactive materials into 
the body for a single plane display of 
images developed from the capture of 
radioactive emissions


Nuclear Medicine

Root Type 

Tomographic(Tomo) Imaging

Introduction of radioactive materials into 
the body for three dimensional display of 
images developed from the capture of 
radioactive emissions


Nuclear Medicine

Root Type 

Positron Emission 

Tomographic(PET) Imaging

Introduction of radioactive materials into 
the body for three dimensional display of 
images developed from the simultaneous 
capture, 180 degrees apart, of radioactive 
emissions


Nuclear Medicine 

Root Type 

NonimagingUptake

Introduction of radioactive materials into 
the body for measurements of organ 
function, from the detection of radioactive 
emissions


Nuclear Medicine 

Root Type 

NonimagingProbe

Introduction of radioactive materials into the 
body for the study of distribution and fate of 
certain substances by the detection of 
radioactive emissions; or, alternatively, 
measurement of absorption of radioactive 
emissions from an external source


Nuclear Medicine 

Root Type 

NonimagingAssay

Introduction of radioactive materials into 
the body for the study of body fluids and 
blood elements, by the detection of 
radioactive emissions


Nuclear Medicine

Root Type

Systemic Therapy

Introduction of unsealed radioactive 
materials into the body for treatment


Nuclear Medicine Section

Body Part

(Character 4)

..Indicates the body part or region to the 
degree of specificity that is usual and 
appropriate for the section 
..Regional (e.g., lower extremity veins) and 
combination body parts (e.g., liver and 
spleen) are commonly used



Nuclear Medicine Section 

Radionuclide 

(Character 5)

..Character 5 is the source of the radiation
..An Other Radionuclideoption is included for 
new FDA approved radiopharmaceuticals



Radiation Oncology 
Section


Radiation Oncology Section

Character Specification

1234567SectionBody SystemModality Qualifier 
IsotopeQualifierRoot TypeTreatment Site

Radiation Oncology Section 

Root Type

(Character 3)

Classified by the basic mode of radiation 
delivery used:

Beam Radiation
Brachytherapy
StereotacticRadiosurgery
Other Radiation



Radiation Oncology Section 

Treatment Site

(Character 4)

Specifies the body part that is the target of the 
radiation therapy


Radiation Oncology Section 

Modality Qualifier

(Character 5)

Further specifies the type of radiation used:

photons
electrons
heavy particles
contact radiation



Radiation Oncology Section 

Isotope

(Character 6)

..Specifies the isotope administered in 
oncology treatments



Physical Rehabilitation 

and

Diagnostic Audiology

Section


Physical Rehabilitation and 

Diagnostic Audiology

Character Specification

1234567SectionSection QualifierType Qualifier 
EquipmentQualifierRoot TypeBody System and Region

Physical Rehabilitation and

Diagnostic Audiology

Root Type

(Character 3)

Treatment: 

Use of specific activities or methods to develop, improve 
and/or restore the performance of necessary functions, 
compensate for dysfunction and /or minimize debilitation

Assessment: 

Includes a determination of the patients diagnosis when 
appropriate, need for treatment, planning for treatment, 
periodic assessment and documentation related to these 
activities


Physical Rehabilitation and 

Diagnostic Audiology

Root Type

(Character 3)

..Fitting(s):


Design, fabrication, modification, selection and/or 
application of splint, orthosis, prosthesis, hearing aids 
and/or rehabilitation device

..Caregiver Training: 


Educating caregiver with the skills and knowledge used 
to interact with and assist the patient


Physical Rehabilitation and 

Diagnostic Audiology

Body System and Region

(Character 4)

..Body Systems
Neurological System
Circulatory System 
Respiratory System 
IntegumentarySystem 
Musculoskeletal System
Genitourinary System
..Body Regions


-Head and Neck

-Upper Back/Upper Extremity

-Lower Back/Lower Extremity

-Whole Body


Physical Rehabilitation and 

Diagnostic Audiology

Type Qualifier 

(Character 5)

Specifies the precise test or method employed

Examples:

Therapeutic exercise treatment

Dressing or transfer assessment

Prosthesis fitting

Transfer caregiver training


Physical Rehabilitation and 

Diagnostic Audiology

Equipment

(Character 6)

..Specific types of equipment are not listed
..General categories of equipment are listed 
(e.g., physical agents, mechanical 
modalities, assistive/adaptive/supportive 
devices)



Mental Health Section


Mental Health Section

Character Specification

1234567SectionBody SystemRoot TypeQualifierQualifierQualifierType Qualifier

Mental Health Section 

Root Type

(Character 3)

Psychological Tests

Crisis Intervention

Medication Management

Individual Psychotherapy

Counseling

Family Psychotherapy

Electroconvulsive Therapy 

Biofeedback 

Hypnosis

Narcosynthesis

Group Therapy 

Light Therapy


Mental Health Section 

Type Qualifier 

(Character 4)

..Type qualifier provides additional 
specificity
..Not all types have type qualifier 



Mental Health Section 

Type Qualifier 

(Character 4)

Example:

Psychological Tests

..Developmental Testing 
..Personality and Behavioral Testing
..Intellectual and PsychoeducationalTesting
..Neuropsychological Testing
..Neurobehavioral and Cognitive Status Testing



Mental Health Section 

Qualifier 

(Character 5 -7 )

Have a value of ZNone


Substance Abuse 
Treatment Section


Substance Abuse Treatment 

Character Specification

1234567SectionBody SystemRoot TypeQualifierQualifierQualifierType Qualifier

Substance Abuse Treatment 

Root Type 

(Character 3)

Detoxification Services

Individual Counseling

Group Counseling

Individual Psychotherapy

Family Counseling

Medication Management

Pharmacotherapy


Substance Abuse Treatment 

Type Qualifier 

(Character 4)

..Type qualifier provides additional 
specificity
..Not all types have type qualifier 



Substance Abuse Treatment 

Type Qualifier 

(Character 4)

Example:

Pharmacotherapy

..Nicotine Replacement Therapy 
..Methadone Maintenance
..LAAM
..Antabuse
..Naltrexone
..Naloxone
..Clonidine
..Bupropion
..Psychiatric Medications
..Other Replacement Medication



Substance Abuse Treatment 

Qualifier 

(Character 5 -7 )

Have a value of ZNone


ICD-10-PCS Testing


ICD-10-PCS Testing

..Tested by Clinical Data Abstraction Centers 
(CDACs)
FMAS, Columbia, MD
DynKePRO, York, PA
..Coded 5,000 records
Offered feedback on issues found
Suggested improvements
..Additional comparison test of 100 records
..Additional testing on ambulatory records



Major Modifications as 

a Result of Testing

..Limited Not Otherwise Specified (NOS) 
options added
..Number of approaches reduced
..Training manual revised
..Index entries added



Testing Findings

..More complete than ICD-9-CM, greater 
specificity
..Easy to expand the system
..Multi-axial structure makes it easier to 
analyze
..Standardized terminology makes it easier to 
use once the coder has initial training



Testing Findings

Initial training time will be a factor since it 
differs significantly from ICD-9-CM

Having all terms defined makes it easier to 
teach
Once basic knowledge is acquired, the coder 
does not use the index



