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by Joe Rivet, JD, CCS-P, CPC, CEMC, CHC, CCEP, CHRC, CHPC, CICA, CPMA, CAC, CACO
Each character in the ICD-10-PCS code represents a specific element. The anatomy of the code is the following:
- First character: refers to which section (i.e., Medical and Surgical, Obstetrics)
- Second character: refers to the body system (i.e., Central nervous system)
- Third character: refers to the root operations (i.e., Bypass, Excision)
- Fourth character: refers to the body part (i.e., coronary vein, left leg)
- Fifth character: refers to the approach of the procedure (i.e., open, percutaneous)
- Sixth character: refers to the device (i.e., autologous tissue substitute)
- Not all procedures will have a device, and in which case, the device would be “Z”
- Seventh character: refers to the qualifier (i.e., diagnostic)
- Not all procedures will have a qualifier, in which case, the qualifier would be “Z”
After you have identified the first three or more characters in the Alphabetic Index, then move to the appropriate ICD-10-PCS table to complete the code. You need a complete, seven-character procedure code, and the remaining characters will be found within the selected table.
Within the chosen table, there are several combinations of character choices for each of the remaining characters four through seven.
When using a table, you can only select codes four through seven from the same row. Meaning, the body part, approach, device, and qualifier must all be in the same row within a table. You cannot have a body part in one row and select an approach from another row in the same table; the code would be invalid.
Editor’s note: Rivet is a partner with the American Regulatory Compliance Society in Grand Haven, Michigan. His experience includes conducting fraud, waste, and abuse audits across a wide variety of services and provider settings. He is a national speaker and has published two books along with numerous articles. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries. Want to write for the ACDIS Blog? Contact ACDIS Associate Editor Carolyn Riel today!
In ICD-10-PCS coding, the root operation must be determined at the start of trying to assign a specific code for the procedure. The root operation is the third character in the PCS code and describes the intent or the objective of the procedure.
Most PCS codes reported for the inpatient setting are found in the Medical and Surgical section of ICD-10-PCS. There are 31 root operations in this section. The entire list can be found with definitions and examples beginning on page 117 of the ICD-10-PCS Reference Manual.
Root operation groups for the Medical and Surgical section share similar attributes. Below is a list that show each group and which root operations are included in the description (this is only for the Medical/Surgical section and the other sections will be addressed in a later document).
Medical and Surgical Section/Root Operation Groups
- Root operations that take out some or all of a body part include Excision, Resection, Detachment, Destruction, and Extraction.
- Root operations that take out solids/fluids/gases from a body part include Drainage, Extirpation, and Fragmentation.
- Root operations involving cutting or separation only include Division and Release.
- Root operations that put in/put back or move some/all of a body part include Transplantation, Reattachment, Transfer, and Reposition.
- Root operations that alter the diameter/route of a tubular body part include Restriction, Occlusion, Dilation, and Bypass.
- Root operations that always involve a device include Insertion, Replacement, Supplement, Change, Removal, and Revision.
- Root operations involving examination only include Inspection and Map.
- Root operations that define other repairs include Control and Repair.
- Root operations that define other objectives include Fusion, Alteration, and Creation.
The full definition of the root operation in the PCS Tables must be applied when determining the correct root operation.
The MD is not expected to use the terms used in PCS. The coder is not required to query the physician if the coder can correlate what the MD has documented to the correct root operation (i.e., partial resection to the root operation excision).
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.