icd - 10 pcs self review manual
TRANSCRIPT
ICD-10 PCS Self ReviewPrepared by: Maria Kuch
Resources:2016 ICD-10 PCS Coder Training Manual AHIMA
Comprehensive Medical Coding : Lorraine Papazian - Boyce
2016 The Official ICD-10 PCS Code Book
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7 CHARACTERS
Character 1:SECTION
Character 2: BODY SYSTEM
Character 3: ROOT OPERATION
Character 4: BODY PART
Character 5: APPROACH
Character 6: DEVICE
Character 7: QUALIFIER
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CHARACTERS Definition
Character 1:SECTION - is defined as the broad procedure category where the code is found. Or the general type of procedure.
EXAMPLE: The Medical and Surgical SECTION is found under “0” value.
0 Medical and Surgical
2 Heart and Great Vessel
7 Dilation
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Character 2: BODY SYSTEM
Body System is defined in which the procedure is performed or the anatomical region where the procedure is performed, such as central nervous system or skeletal system.
Example:
0 - SECTION
N - HEAD & FACIAL BONES
Note Skeletal System is divided in 5 body system
Head & facial bones, upper bones, lower bones, upper joint etc.
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Character 2: BODY SYSTEM for Skeletal
N Head & Facial Bones
P Upper Bones
Q Lower Bones
R Upper Joints
S Lower Joints
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Character 3: ROOT OPERATION
ROOT Operation is defined as the 3rd character and describe the objective of the procedure such as excision, destruction, etc.
Example:
0 Medical and Surgical : SECTION
K Muscle : BODY SYSTEM
9 Drainage: ROOT OPERATION
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TABLE LIST OF ROOT OPERATION - Examples
ROOT OPERATIONWHAT
OPERATION DOESOBJECTIVES OF PROCEDURES
PROCEDURE SITE EXAMPLE
Excision Takes out some/all of the body
Cutting out/off without
replacement
Some of the body part
Breast Lumpectomy
DrainageTakes out solids/fluids/gases from
body
Taking/letting out fluids/gases
Within the body part Incision & drainage
Division Involved cutting or separation only
Cutting into/separating a body
part
Within the body part Neurotomy
Transplantation
Puts in/puts back or moves some all of a body part
Putting in a living body part from a
person/animal
Some/all of a body part Kidney Transplant
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Character 4: BODY PART
BODY PART defines the specific anatomical site where the procedure is performed.Body part may specify laterality.
Example:
BODY SYSTEM - Lower Extremities
In BODY PART it could be LEFT FOOT
Central Nervous = Trigeminal Nerve
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Character 5 APPROACHAPPROACH is defines as the technique used to reach the site of the procedure such as open, endoscopic, or external.
There are 7 different approaches. The Approach is comprised of 3 components: the access location, method, & type of instrumentation.
ACCES LOCATION - specifies the external site through which the procedure is reached.
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3 Components of Approach
ACCES LOCATION - specifies the external site through which the procedure is reached.
There are 2 general type of access locations: SKIN or MUCOUS membranes and external orifices.
Skin or mucous can be cut or punctured to reach the procedure site, OPEN & PERCUTANEOUS approach values use this access location. External opening which can be natural (mouth) or artificial (colostomy)
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Components of Approachcontinue..
Method - specifies how the external access location is entered.
OPEN method = Cutting through the skin or mucous membrane
TYPE OF INSTRUMENTATION - refers to the specialized equipment used to perform the procedure.
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APPROACH DefinitionOPEN
Cutting through the skin or mucous membrane & any other body layers necessary to expose the site of the procedure
PERCUTANEOUSEntry, by puncture or minor incision, of instrumentation through the skin or mucous membrane &/or any other body layers necessary to reach the site of the procedure
PERCUTANEOUS ENDOSCOPIC
Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane &/or any other body layers necessary to reach and visualize the site of the
procedure.
VIA NATURAL OR ARTIFICIAL OPENING
Entry of instrumentation through natural or artificial external opening to reach the site of the procedure
VIA NATURAL OR ARTIFICIAL OPENING
ENDOSCOPIC
Entry of instrumentation through natural or artificial external opening to reach and visualize the site of the procedure
VIA NATUAL OR ARTIFICIAL OPENING
ENDOSCOPIC W/PERCUTANEOUS ENDOSCOPIC ASSISTANCE
Entry of instrumentation through a natural or artificial opening to reach & visualize the site of the procedure, & entry, by puncture or minor incision, of instrumentation through the
skin or mucous membrane & any other body layers necessary to aid in the performance of the procedure
EXTERNALProcedure performed directly on the skin or mucous membrane and procedures performed
indirectly by the application of external force through the skin or mucous membrane
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APPROACH VALUES0 Open
3 Percutaneous
4 Percutaneous Endoscopic
7 Via Natural or Artificial Opening
8 Via Natural or Artificial Opening Endoscopic
F Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance
X External
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