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2021DESK REFERENCEoptum360coding.comFind product details and features —including item number, ISBN number andavailability date — quickly and easily.Intuitive product organizationStreamlined checkoutOptum360 coding products areorganized by category so you can findwhat you need quickly and easily.View and edit your cart, ship to multiplerecipients, add payment information,assign a PO number and complete yourpurchase — all on one page.Sign in to check outSigning in prior to checkout ensuresyour online and offline transactions areseamlessly linked to the same account foryour convenience. Don’t have an onlineaccount? It’s easy to create one — visitoptum360coding.com/register.Visit optum360coding.comITDRP21/ITDRP Made in the USAView all your accountinformationGet immediate access to your order andinvoice history, track shipments, renew aproduct, create a wish list or update yourcontact information. 2020 Optum360, LLC. All rights reserved.WF2305592 04/20PLEEffortlessly view our new website onany device — desktop, tablet orsmartphone — optum360coding.comis with you wherever you go.Product information atyour fingertipsClinical descriptions with answers to yourtoughest ICD-10-PCS coding questionsMDevice-friendly shoppingCoders’ Desk Referencefor ICD-10-PCS ProceduresSAThe redesigned optum360coding.com offers new conveniences and the same greatcoding resources you’ve always trusted for a convenient, seamless shopping experience.Coders’ Desk Reference forICD-10-PCS ProceduresSeamless shopping starts here.2 0 22optum360coding.comITDRP ITDRP21 CVR Final.indd 17/31/2020 9:03:22 AM
ContentsIllustrations . xiIntroduction . 1ICD-10-PCS Overview . 1How to Use Coders’ Desk Reference for ICD-10-PCS Procedures . 2Format . 3PLEICD-10-PCS Official Guidelines for Coding and Reporting 2021 . 7Conventions . 7Medical and Surgical Section Guidelines (section 0) . 8Obstetric Section Guidelines (section 1) .15Radiation Therapy Section Guidelines (section D) .15New Technology Section Guidelines (section X) .15ICD-10-PCS Root Operation Definitions . 17Root Operation Definitions for Other Sections .21Abbreviations, Acronyms, and Symbols . 25Procedure Eponyms . 43Surgical Terms . 75SAMMedical and Surgical . 83Abdominoplasty .83Ablation, Cardiac Conduction Tissue .84Ablation, Endometrial .85Ablation, Vein, Thermal, Endovenous .86Adenoidectomy (without Tonsillectomy) .87Adjustment, Cardiac Pacemaker Lead .88Adrenalectomy, Unilateral .89Alveoloplasty .90Alveolotomy .91Amputation, Below Knee .92Amputation, Foot and Toe Ray .93Amputation, Toe .94Amygdalohippocampectomy .95Anastomosis, Billroth I .96Anastomosis, Billroth II .97Aneurysmectomy, Abdominal Aortic, with Replacement .98Angioplasty, Percutaneous Transluminal Coronary (PTCA) .99Angioplasty, Percutaneous Transluminal Coronary (PTCA) with Stent(s) . 100Angioplasty, Percutaneous Transluminal (PTA), Lower Extremity . 101Angioplasty, Percutaneous Transluminal (PTA), Lower Extremity, with Stent . 102Arterioplasty (Bovine Patch) . 103Arthrocentesis . 104Atherectomy, Percutaneous Transluminal, Coronary, Rotational . 105Banding, Gastric, Laparoscopic Adjustable (LAGB) (Lap-Band System) . 106Biopsy, Bone Marrow . 107Biopsy, Liver . 108Biopsy, Lung, Transbronchial . 110Biopsy, Lymph Node . 111Biopsy, Periurethral Tissue . 112Biopsy, Temporal Artery . 113Blalock-Taussig Shunt Procedure, Modified . 113Blepharoplasty . 114 2021 Optum360, LLCi
ContentsSAMPLEExcision, Lingual, Submucosal Minimally Invasive (SMILE) . 172Excision, Radical, Skin Lesion . 173Excision, Radioulnar Synostosis . 174Excision, Thoracic Spinal Dural Arteriovenous Fistula . 175Exploration, Common Bile Duct . 176Exploratory Laparotomy/Laparoscopy . 177Extraction, Extracapsular Cataract with Intraocular Lens Implantation . 178Fasciectomy, Plantar . 179Fasciotomy, Palmar (Dupuytren's Contracture) . 180Fistula, Arteriovenous (AV) . 181Fistulectomy, Anal . 182Fistulectomy, Vesicovaginal . 183Fistulotomy, Anal . 184Fontan Stage I (Norwood Procedure) . 185Fontan Stage II (Glenn Procedure) (Caval-pulmonary Artery Anastomosis) . 186Fontan Stage III, Completion . 187Frenectomy, Labial . 188Frenotomy, Labial . 188Fundoplication, Gastroesophageal . 189Fusion, Ankle (Arthrodesis) . 190Fusion, Cervical Spine, Anterior (ACF) . 191Fusion, Cervical Spine, Posterior (PCF) . 193Fusion, Lumbar, Anterior Interbody (ALIF) (Anterior Lumbar Vertebral Arthrodesis) . 195Fusion, Lumbar, Posterior (PLF) . 197Gastrectomy . 199Gastrectomy, Vertical Sleeve (VSG) . 200Gastrojejunostomy, Roux-en-Y (Gastric Bypass for Morbid Obesity) . 201Gastroplasty, Collis . 202Gastrostomy, Percutaneous Endoscopic (PEG) . 203Gender Reassignment Surgery . 204Genioplasty, Augmentation . 205Graft, Arterial, Chimney (Stent) . 206Graft, Arteriovenous (AV) . 207Graft, Dura Mater, Intracranial . 208Graft, Skin, Split-Thickness (STSG) . 209Graft, Sphenoid Sinus (Fat) . 210Harvest, Graft, Autologous Bone Marrow . 211Harvesting, Knee Chondrocytes . 212Hemicolectomy . 213Hemorrhoidectomy . 214Herniorrhaphy, Femoral . 215Herniorrhaphy, Inguinal . 216Herniorrhaphy, Paraesophageal (Diaphragmatic) . 217Herniorrhaphy, Ventral, Incisional (Hernia Repair) . 218Hysterectomy . 219Implant, Cochlear (CI) . 221Implantation, Artificial Urinary Sphincter (AUS) . 222Implantation, Autologous Chondrocyte (ACI), Knee . 223Implantation, Biventricular Heart Replacement System (Artificial Heart) . 224Implantation, Epiretinal Visual Prosthesis . 225Incision and Loop Drainage, Suprapubic Subcutaneous Abscess . 226Insertion, Baclofen Pump . 227Insertion, Bone Growth Stimulator . 228Insertion, Brachytherapy, Radioactive Element . 229 2021 Optum360, LLCiii
ContentsMPLEThrombectomy, Percutaneous Mechanical (Pharmacomechanical) (PMT) . 395Thyroidectomy . 396Tonsillectomy, Lingual . 398Tonsillectomy (Without Adenoidectomy) . 399Tonsillectomy with Adenoidectomy . 400Trabeculectomy Ab Externo . 401Trabeculoplasty, Laser . 402Tracheostomy . 403Tracheostomy Revision (Stomaplasty) . 404Tracheostomy Tube Change . 405Transfer, Lymph Node (LNT) . 406Transplant, Heart . 407Transplant, Kidney . 408Transplant, Liver . 409Transplant, Lung . 410Transplant, Meniscus . 411Transplant, Uterus . 412Transposition, Nerve . 413Turbinectomy, Submucous Resection . 414Ureteroneocystostomy . 415Ureteroplasty . 416Urethropexy (Retropubic Urethral Suspension) . 417Uvulopalatopharyngoplasty . 418Valvotomy (Valvulotomy) . 419Valvuloplasty . 420Vasectomy . 422Ventriculostomy . 423Ventriculostomy, Reopening, Endoscopic Third (ETV) . 425Vertebroplasty . 426Vitrectomy . 427Washing, Bronchial . 428Wedge Resection, Mitral Valve Leaflet . 429Whipple . 430Z-plasty, Skin (Scar Revision) . 431SAMedical and Surgical-Related . 433Obstetrics . 433Abortion . 433Amniocentesis . 435Cesarean Section (C-section) . 436Delivery, Assisted, Manually . 437Delivery, Assisted with Instrumentation . 438Delivery, Vaginal, Breech . 440Extraction, Retained Placenta, Manual . 441Insertion, Monitoring Electrode . 442Removal, Ectopic Pregnancy . 443Repair, In Utero Fetal Myelomeningocele . 444Version, External Cephalic (ECV) . 445Placement . 446Application, Stereotactic Head Frame . 446Compression, Lymphedema, Intermittent Pneumatic . 446Immobilization (Cast/Splint) . 447Packing . 448Traction . 449 2021 Optum360, LLCvii
Introductionspecific option for the general character definition. The10 digits 0–9 and the 24 letters A–H, J–N, and P–Z maybe used for each character. The letters O and I are notused so as to avoid confusion with the digits 0 and 1.PLEAn ICD-10-PCS code is the result of a process ratherthan a single fixed set of digits or alphabeticcharacters. The process consists of combiningsemi-independent values from among a selection ofvalues, according to the rules governing theconstruction of codes. A code is derived by choosing aspecific value for each of the seven characters. Basedon details about the procedure performed, values areassigned for each character specifying the section,body system, root operation, body part, approach,device, and qualifier. Because the definition of eachcharacter is also a function of its physical position inthe code, the same letter or number placed in adifferent position in the code has a different meaning.MThis book provides coders, coding managers, medicalstaff and health care professionals, payers, educators,and students with comprehensive, clear descriptionsof procedures. The goal is to enrich users’ clinicalunderstanding of surgical procedures and how theyrelate to the way ICD-10-PCS classifies procedures. Theresult is improved coding confidence so that codeselection becomes more accurate and efficient. Thecoding guidance in Coders’ Desk Reference forICD-10-PCS Procedures is based on the official version ofthe ICD-10 Procedure Coding System (ICD-10-PCS),effective October 1, 2020. (Please note that thisprocedure coding reference is intended to be usedwith an official ICD-10-PCS code book.)This desk reference is organized by common procedurenomenclature used in the hospital setting, which islinked to the related root operation tables. Theprocedures are described in layman’s terms, translatedto ICD-10-PCS root operation terminology, and thecorresponding root operation tables are identified.SADetailed descriptions using terminology coders see inmedical documents, together with coding clarificationand guidance and important instruction regardingICD-10-PCS conventions, make Coders’ Desk Referencefor ICD-10-PCS Procedures an unparalleled guidebookto code selection.Important Message: Not all categories, subcategories,or procedures have been represented in this edition ofthe Coders’ Desk Reference for ICD-10-PCS Procedures.Additional procedures not part of the 2021 edition willgradually be incorporated into future editions.ICD-10-PCS OverviewICD-10-PCS Code StructureICD-10-PCS has a multiaxial, seven-character,alphanumeric code structure. Each character containsup to 34 possible values. Each value represents a 2021 Optum360, LLCT
result is improved coding confidence so that code selection becomes more accurate and efficient. The coding guidance in Coders' Desk Reference for ICD-10-PCS Procedures is based on the official version of the ICD-10 Procedure Coding System (ICD-10-PCS), effective October 1, 2020. (Please note that this
