Procedure Coding:
Using the ICD-10-PCS

Job Aid

Selecting the Correct Code

To find the correct ICD-10-PCS code, follow these steps:

Step 1: Use the Index to find the right ICD-10-PCS table and look up the first 3 values of the code.

Step 2: Use the ICD-10-PCS table to find values 4-7 of the code.

Note: You don’t have to refer to the Index before going to the Tables to complete the code. As you learn more, you can select a valid code directly from the Tables.

Index

The purpose of the Index is to locate the correct table that has all the information you need to build a procedure code.

The Index provides the first 3 or 4 values of the code or directs you to see another item. Find the corresponding table based on the first 3 values of the code in the Index. Then, consult the Tables to find the correct code.

Find codes in the Index based on the general procedure or a common procedure term like appendectomy. You’ll find secondary entries underneath the main term.

Tables

Each ICD-10-PCS table consists of 2 main sections. The upper part of each table has the description of the first 3 characters of the procedure code. Each row in the lower part of the table specifies the valid combination of values for characters 4-7.

ICD-10-PCS Sections

The 7 characters that make up a complete code have specific meanings that vary in each of the 17 sections. The first character of the procedure code always specifies the section. For example, all procedure codes in the Medical and Surgical section begin with the section value 0.

Table 1. Table listing section values and the section of codes to which they apply

Medical and Surgical Section Guidelines

General guidelines for the Medical and Surgical section of ICD-10-PCS include:

• Use the procedure codes in the general anatomical region body systems when the procedure is performed on an anatomical region rather than a specific body part. Use these codes on the rare occasion when no information is available to support assignment of a code to a specific body part.
• Where the general body part values upper and lower are given, upper or lower specifies body parts located above or below the diaphragm, respectively.
• Apply the full definition of the root operation as contained in the ICD-10-PCS Tables to determine the appropriate root operation.
• Don’t code these separately:
  • Components of a procedure specified in the root operation definition and explanation as integral to that root operation
  • Procedural steps necessary to reach the operative site and close the operative site, including anastomosis of a tubular body part
• If the intended procedure is discontinued or otherwise not completed, code the procedure to the root operation performed. If a procedure is discontinued before any other root operation is performed, code the root operation Inspection of the body part or anatomical region inspected.
• Code biopsy procedures using the root operations Excision, Extraction, or Drainage and the qualifier Diagnostic. For example, code biopsy of bone marrow to the root operation Extraction with the qualifier Diagnostic.
• If a procedure is performed on a portion of a body part that doesn’t have a separate body part value, code the body part value corresponding to the whole body part.
• Where a specific branch of a body part doesn’t have its own body part value in PCS, code the body part to the closest proximal branch with a specific body part value.
• Bilateral body part values are available for a limited number of body parts. If the identical procedure is performed on contralateral body parts, and a bilateral body part value exists for that body part, code a single procedure using the bilateral body part value. If no bilateral body part value exists, code each procedure separately using the appropriate body part value.
• The coronary arteries are classified as a single body part that’s further specified by number of arteries treated. Use 1 procedure code to specify multiple arteries when the same procedure is performed, including the same device and qualifier values.
• Code procedures performed using the open approach with percutaneous endoscopic assistance to the approach Open.
• Code procedures performed indirectly by the application of external force through the intervening body layers to the approach External.
• Code procedures performed percutaneously via a device placed for the procedure to the approach Percutaneous.

Device Guidelines

Guidelines for coding devices in ICD-10-PCS include:

• Code a device only if it remains after the procedure is completed. If no device remains, code the device value No Device.
• Materials such as sutures, ligatures, radiological markers, and temporary post-operative wound drains are integral to the performance of a procedure. Don't code them as devices.
• Procedures performed only on a device and not on a body part are specified in the root operations Change, Irrigation, Removal, and Revision. Code them to the procedure performed.
• Code a separate procedure to put in a drainage device to the root operation Drainage with the device value Drainage Device.

ICD-10-PCS Conventions

ICD-10-PCS conventions include:

• Each character of the 7-character ICD-10-PCS code is an axis of classification that specifies information about the procedure performed. Within a defined code range, a character specifies the same type of information in that axis of classification. For example, the fifth axis of classification specifies the approach in sections 0-4 and 7-9 of the system.
• The valid values for an axis of classification can be added as needed. For example, if a significantly distinct type of device is used in a new procedure, a new device value can be added to the system.
• The meaning of any single value is a combination of its axis of classification and any preceding values on which it may depend. For example, the meaning of a body part value in the Medical and Surgical section is always dependent on the body system value. The body part value 0 in the Central Nervous System and Cranial Nerves body system specifies Brain, and the body part value 0 in the Peripheral Nervous System body system specifies Cervical Plexus.
• When "and" is used in a code description, interpret it as "and/or," except when used to describe a combination of multiple body parts for which separate values exist for each body part (for example, Skin and Subcutaneous Tissue used as a qualifier, where there are separate body part values for "Skin" and "Subcutaneous Tissue"). For example, Lower Arm and Wrist Muscle means lower arm and/or wrist muscle.
• Section X, New Technology, provides a place for codes for certain new technology procedures, like infusion of new technology drugs, not currently classified in ICD-10-PCS.
• ICD-10-PCS has no combination codes. It rarely defines multiple procedures with 1 code to preserve standardized terminology and consistency across the system. Separately code procedures that meet criteria for reporting separate procedures.

Determining a Correct ICD-10-PCS Code

Coding Example 1

Procedure: Excision of right lower arm and wrist tendon, open approach

Step 1: Locate the main term entry Excision in the Index for the type of procedure. The subterms Tendon, Lower Arm and Wrist, Left, and Right direct the user to Table 0LB to complete the code.

Step 2: Locate Table 0LB, which shows the possible value choices for the last 4 characters of the code. You need all 7 characters to complete the code.

Table 2. Table 0LB

This table shows the correct value for each character of the code.

Code Assignment for this Procedure: 0LB50ZZ

Coding Example 2

Procedure: Resection of appendix, percutaneous endoscopic approach

Step 1: Locate the main term entry Appendectomy in the Index for the type of procedure. The subterm Resection, Appendix directs the user to Table 0DT to complete the code.

Step 2: Locate Table 0DT, which shows the possible value choices for the last 4 characters of the code. You need all 7 characters to complete the code.

Table 3. Table 0DT

This table shows the correct value for each character of the code.

Code Assignment for this Procedure: 0DTJ4ZZ

Coding Example 3

Procedure: Excision of sigmoid colon, via natural or artificial opening endoscopic, diagnostic

Step 1: Locate the main term entry for Excision in the Index for the type of procedure. The subterm Colon directs the user to Table 0DB to complete the code.

Step 2: Locate Table 0DB, which shows the possible value choices for the last 4 characters of the code. You need all 7 characters to complete the code.

Table 4. Table 0DB

This table shows the correct value for each character of the code.

Code Assignment for this Procedure: 0DBN8ZX

Coding Example 4

Procedure: Bypass trachea to cutaneous with tracheostomy device, open approach

Step 1: Locate the main term entry for Tracheostomy in the Index for the type of procedure. The subterm Bypass, Respiratory System directs the user to Table 0B1 to complete the code.

Step 2: Locate Table 0B1, which shows the possible value choices for the last 4 characters of the code. You need all 7 characters to complete the code.

Table 5. Table 0B1

This table shows the correct value for each character of the code.

Code Assignment for this Procedure: 0B110F4

Coding Example 5

Procedure: Bypass coronary artery, one artery from right internal mammary, open approach

Step 1: Locate the main term entry for Bypass in the Index for the type of procedure. The subterm One Artery directs the user to Table 021 to complete the code.

Step 2: Locate Table 021, which shows the possible value choices for the last 4 characters of the code. You need all 7 characters to complete the code.

Table 6. Table 021

This table shows the correct value for each character of the code.

Code Assignment for this Procedure: 02100Z8

Coding Example 6

Procedure: Introduction of fosfomycin anti-infective into central vein, percutaneous approach, new technology group 11

Step 1: Locate the main term entry in the Index. Fosfomycin Anti-infective is the main term, and the first 3 values of the code are XW0. The name of the New Technology Device, Substance, or Technology is a subterm. All codes available in Section X are in the Index under the main term New Technology.

Step 2: Locate Table XW0, which shows the possible value choices for the last 4 characters of the code. You need all 7 characters to complete the code. New Technology codes are displayed with separate tables for each root operation and body system, like all other ICD-10-PCS tables.

Table 7. Table XW0

This table shows the correct value for each character of the code.

Code Assignment for this Procedure: XW043WB

The Section X code fully identifies administration of fosfomycin anti-infective. You don’t need to include any other codes, including separate codes from Table 3E0 in the Administration section.