Transcription
Table of ContentsIntroduction to ICD-10-PCS . . . . . . . . . . . . . . . . . . . . . 1Development of the ICD-10 Procedure CodingSystem (ICD-10-PCS). . . . . . . . . . . . . . . . . . . . . . . 1ICD-10-PCS Structure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1ICD-10-PCS Format . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Medical and Surgical Section. . . . . . . . . . . . . . . . . . . . 2Medical and Surgical Section Principles . . . . . . . . . . . 4Obstetrics Section . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Placement Section. . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Administration Section . . . . . . . . . . . . . . . . . . . . . . . . 6Measurement and Monitoring Section . . . . . . . . . . . . . 6Extracorporeal Assistance and Performance Section . . 7Extracorporeal Therapies Section . . . . . . . . . . . . . . . . 7Osteopathic Section . . . . . . . . . . . . . . . . . . . . . . . . . . 7Other Procedures Section . . . . . . . . . . . . . . . . . . . . . . 8Chiropractic Section . . . . . . . . . . . . . . . . . . . . . . . . . . 8Imaging Section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Nuclear Medicine Section . . . . . . . . . . . . . . . . . . . . . . 9Radiation Therapy Section . . . . . . . . . . . . . . . . . . . . . . 9Physical Rehabilitation andDiagnostic Audiology Section . . . . . . . . . . . . . 9Mental Health Section. . . . . . . . . . . . . . . . . . . . . . . . 10Substance Abuse Treatment Section . . . . . . . . . . . . . 10New Technology Section. . . . . . . . . . . . . . . . . . . . . . . 11Modifications to ICD-10-PCS . . . . . . . . . . . . . . . . . . . . . . . 11Number of Codes in ICD-10-PCS . . . . . . . . . . . . . . . . . . . . 12Changes for 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12ICD-10-PCS Expert Icon Explanations . . . . . . . . . . . . 152021 ICD-10-PCS OfficialGuidelines for Coding and Reporting . . . . . . . . . . . . . 17Conventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Medical and Surgical Section Guidelines (Section 0). . . . .Obstetrics Section Guidelines (Section 1). . . . . . . . . . . . .Radiation Therapy Section Guidelines (Section D). . . . . . .New Technology Section Guidelines (Section X) . . . . . . . .Selection of Principal Procedure . . . . . . . . . . . . . . . . . . . .171821212222Coding Practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23ICD-10-PCS Alphabetic Index. . . . . . . . . . . . . . . . . . . 27ICD-10-PCS Coding Section Tables. . . . . . . . . . . . . . 119Central Nervous System andCranial Nerves 001–00X. . . . . . . . . . . . . . . .Peripheral Nervous System 012–01X . . . . . . . . . . . . .Heart and Great Vessels 021–02Y . . . . . . . . . . . . . . .Upper Arteries 031–03W. . . . . . . . . . . . . . . . . . . . . . .Lower Arteries 041–04W . . . . . . . . . . . . . . . . . . . . . .Upper Veins 051–05W. . . . . . . . . . . . . . . . . . . . . . . . .Lower Veins 061–06W. . . . . . . . . . . . . . . . . . . . . . . . .Lymphatic and Hemic Systems 072–07Y . . . . . . . . . .Eye 080–08X. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ear, Nose, Sinus 090–09W . . . . . . . . . . . . . . . . . . . . .119128134145156167176185192202Respiratory System 0B1–0BY. . . . . . . . . . . . . . . . . . .Mouth and Throat 0C0–0CX. . . . . . . . . . . . . . . . . . . .Gastrointestinal System 0D1–0DY. . . . . . . . . . . . . . . .Hepatobiliary System and Pancreas 0F1–0FY. . . . . . .Endocrine System 0G2–0GW. . . . . . . . . . . . . . . . . . . .Skin and Breast 0H0–0HX. . . . . . . . . . . . . . . . . . . . . .Subcutaneous Tissue and Fascia 0J0–0JX. . . . . . . . . .Muscles 0K2–0KX. . . . . . . . . . . . . . . . . . . . . . . . . . . .Tendons 0L2–0LX . . . . . . . . . . . . . . . . . . . . . . . . . . . .Bursae and Ligaments 0M2–0MX. . . . . . . . . . . . . . . .Head and Facial Bones 0N2–0NW. . . . . . . . . . . . . . . .Upper Bones 0P2–0PW. . . . . . . . . . . . . . . . . . . . . . . .Lower Bones 0Q2–0QW. . . . . . . . . . . . . . . . . . . . . . . .Upper Joints 0R2–0RW. . . . . . . . . . . . . . . . . . . . . . . .Lower Joints 0S2–0SW. . . . . . . . . . . . . . . . . . . . . . . .Urinary System 0T1–0TY. . . . . . . . . . . . . . . . . . . . . . .Female Reproductive System 0U1–0UY. . . . . . . . . . . .Male Reproductive System 0V1–0VX . . . . . . . . . . . . .Anatomical Regions, General 0W0–0WY. . . . . . . . . . .Anatomical Regions, Upper Extremities 0X0–0XY. . . .Anatomical Regions, Lower Extremities 0Y0–0YW . . .Obstetrics 102–10Y . . . . . . . . . . . . . . . . . . . . . . . . . .Placement 2W0–2Y5. . . . . . . . . . . . . . . . . . . . . . . . . .Administration 302–3E1. . . . . . . . . . . . . . . . . . . . . . .Measurement and Monitoring 4A0–4B0 . . . . . . . . . . .Extracorporeal or Systemic Assistanceand Performance 5A0–5A2. . . . . . . . . . . . . .Extracorporeal or Systemic Therapies 6A0–6AB. . . . .Osteopathic 7W0. . . . . . . . . . . . . . . . . . . . . . . . . . . . .Other Procedures 8C0–8E0. . . . . . . . . . . . . . . . . . . . .Chiropractic 9WB . . . . . . . . . . . . . . . . . . . . . . . . . . . .Imaging B00–BY4. . . . . . . . . . . . . . . . . . . . . . . . . . . .Nuclear Medicine C01–CW7. . . . . . . . . . . . . . . . . . . .Radiation Therapy D00–DWY. . . . . . . . . . . . . . . . . . . .Physical Rehabilitation andDiagnostic Audiology F00–F15 . . . . . . . . . . .Mental Health GZ1–GZJ . . . . . . . . . . . . . . . . . . . . . . .Substance Abuse Treatment HZ2–HZ9. . . . . . . . . . . .New Technology X27–XY0. . . . . . . . . . . . . . . . . . . . . 493504506508Appendices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515Appendix A: Medical and Surgical Approach Definitions. .Appendix B: Components of the Medical and SurgicalApproach Definitions . . . . . . . . . . . . . . . . . . . . .Appendix C: Root Operations Definitions. . . . . . . . . . . . .Appendix D: Comparison of Medical and Surgical RootOperations. . . . . . . . . . . . . . . . . . . . . . . . . . . . .Appendix E: Body Part Key . . . . . . . . . . . . . . . . . . . . . . .Appendix F: Body Part Definitions. . . . . . . . . . . . . . . . . .Appendix G: Device Key. . . . . . . . . . . . . . . . . . . . . . . . . .Appendix H: Device Definitions . . . . . . . . . . . . . . . . . . . .Appendix I: Device Aggregation Table . . . . . . . . . . . . . . .Appendix J: Section Definitions . . . . . . . . . . . . . . . . . . . .Appendix K: Coding Practice Quiz Answers. . . . . . . . . . .515516517519521539549555559561569
ICD-10-PCS Tabular List to ProceduresCentral Nervous System and Cranial Nerves 00D–00JCentral Nervous System and Cranial Nerves 00D–00J0 Medical and Surgical0 Central Nervous System and Cranial NervesD Extraction: Pulling or stripping out or off all or a portion of a body part by the use of force12FGHJKLMNPQRSTCharacter 4Body PartCerebral MeningesDura MaterOlfactory NerveOptic NerveOculomotor NerveTrochlear NerveTrigeminal NerveAbducens NerveFacial NerveAcoustic NerveGlossopharyngeal NerveVagus NerveAccessory NerveHypoglossal NerveSpinal MeningesCharacter 5Approach0 Open3 Percutaneous4 Percutaneous EndoscopicCharacter 6DeviceCharacter 7QualifierZ No QualifierCharacter 6DeviceCharacter 7QualifierZ No QualifierZ No DeviceAHA: 00D20ZZ - 3Q 2015, 140 Medical and Surgical0 Central Nervous System and Cranial NervesF Fragmentation: Breaking solid matter in a body part into pieces3456UCharacter 4Body PartEpidural Space, Intracranial NCSubdural Space, IntracranialNCSubarachnoid Space, IntracranialNCCerebral Ventricle NCSpinal CanalCharacter 5Approach034XOpenPercutaneousPercutaneous EndoscopicExternalZ No DeviceNC00F(3/4/5/6)XZZ0 Medical and Surgical0 Central Nervous System and Cranial NervesH Insertion: Putting in a nonbiological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body partCharacter 4Body Part0 BrainCharacter 5ApproachCharacter 7QualifierZ No QualifierMYCharacter 6DeviceRadioactive ElementMonitoring DeviceInfusion DeviceRadioactive Element, Cesium-131Collagen ImplantNeurostimulator LeadOther Device12340 Open0 Brain3 Percutaneous4 Percutaneous Endoscopic123MYRadioactive ElementMonitoring DeviceInfusion DeviceNeurostimulator LeadOther DeviceZ No Qualifier6EUV0 Open3 Percutaneous4 Percutaneous Endoscopic123MYRadioactive ElementMonitoring DeviceInfusion DeviceNeurostimulator LeadOther DeviceZ No QualifierCerebral VentricleCranial NerveSpinal CanalSpinal CordAHA: 00H633Z - Q2 2020, 12; 00HU03Z - Q2 2020, 130 Medical and Surgical0 Central Nervous System and Cranial NervesJ Inspection: Visually and/or manually exploring a body partCharacter 4Body Part0EUVBrainCranial NerveSpinal CanalSpinal CordCharacter 5Approach0 Open3 Percutaneous4 Percutaneous EndoscopicCharacter 6DeviceCharacter 7QualifierZ No QualifierZ No DeviceAHA: 00J00Z - 2Q 2019, 27; 00JU3ZZ - 1Q 2017, 50New and Revised CodesNCNon-covered 2020 DecisionHealth 2021 ICD-10-PCS ExpertLCLimited Coverage Male FemaleAHA AHA Coding Clinic123
Central Nervous System and Cranial Nerves 00K–00NCentral Nervous System and Cranial Nerves 00K–00NICD-10-PCS Tabular List to Procedures0 Medical and Surgical0 Central Nervous System and Cranial NervesK Map: Locating the route of passage of electrical impulses and/or locating functional areas in a body partCharacter 4Body Part0789ABCDBrainCerebral HemisphereBasal GangliaThalamusHypothalamusPonsCerebellumMedulla OblongataCharacter 5Approach0 Open3 Percutaneous4 Percutaneous EndoscopicCharacter 6DeviceCharacter 7QualifierZ No QualifierCharacter 6DeviceCharacter 7QualifierZ No QualifierZ No Device0 Medical and Surgical0 Central Nervous System and Cranial NervesN Release: Freeing a body part from an abnormal physical constraint by cutting or by the use of forceCharacter 4Body Part0126789ABCDFGHJKLMNPQRSTWXYBrainCerebral MeningesDura MaterCerebral VentricleCerebral HemisphereBasal GangliaThalamusHypothalamusPonsCerebellumMedulla OblongataOlfactory NerveOptic NerveOculomotor NerveTrochlear NerveTrigeminal NerveAbducens NerveFacial NerveAcoustic NerveGlossopharyngeal NerveVagus NerveAccessory NerveHypoglossal NerveSpinal MeningesCervical Spinal CordThoracic Spinal CordLumbar Spinal CordCharacter 5Approach0 Open3 Percutaneous4 Percutaneous EndoscopicZ No DeviceAHA: 00N00ZZ - 2Q 2016, 29; 00NC0ZZ - 3Q 2017, 10; 00NM4ZZ - 4Q 2018, 8; 00NW0ZZ - 2Q 2015, 20-22, 2Q 2017, 23; 00NW3ZZ - 2Q 2019, 15; 00NY0ZZ - 1Q 2019, 22, 3Q 2018, 30New and Revised Codes124NCNon-coveredLCLimited Coverage Male FemaleAHA AHA Coding Clinic2021 ICD-10-PCS Expert 2020 DecisionHealth
ICD-10-PCS Tabular List to ProceduresCentral Nervous System and Cranial Nerves 00P–00QCentral Nervous System and Cranial Nerves 00P–00Q0 Medical and Surgical0 Central Nervous System and Cranial NervesP Removal: Taking out or off a device from a body partCharacter 4Body PartCharacter 5Approach0 BrainV Spinal Cord0 Open3 Percutaneous4 Percutaneous Endoscopic0237JKMYCharacter 6DeviceDrainage DeviceMonitoring DeviceInfusion DeviceAutologous Tissue SubstituteSynthetic SubstituteNonautologous Tissue SubstituteNeurostimulator LeadOther DeviceCharacter 7QualifierZ No Qualifier0 BrainV Spinal CordX External023MDrainage DeviceMonitoring DeviceInfusion DeviceNeurostimulator LeadZ No Qualifier6 Cerebral VentricleU Spinal Canal0 Open3 Percutaneous4 Percutaneous Endoscopic023JMYDrainage DeviceMonitoring DeviceInfusion DeviceSynthetic SubstituteNeurostimulator LeadOther DeviceZ No Qualifier6 Cerebral VentricleU Spinal CanalX External023MDrainage DeviceMonitoring DeviceInfusion DeviceNeurostimulator LeadZ No QualifierE Cranial Nerve0 Open3 Percutaneous4 Percutaneous Endoscopic0237MYDrainage DeviceMonitoring DeviceInfusion DeviceAutologous Tissue SubstituteNeurostimulator LeadOther DeviceZ No QualifierE Cranial NerveX External023MDrainage DeviceMonitoring DeviceInfusion DeviceNeurostimulator LeadZ No Qualifier0 Medical and Surgical0 Central Nervous System and Cranial NervesQ Repair: Restoring, to the extent possible, a body part to its normal anatomic structure and functionCharacter 4Body Part0126789ABCDFGHJKLMNPQRSTWXYBrainCerebral MeningesDura MaterCerebral VentricleCerebral HemisphereBasal GangliaThalamusHypothalamusPonsCerebellumMedulla OblongataOlfactory NerveOptic NerveOculomotor NerveTrochlear NerveTrigeminal NerveAbducens NerveFacial NerveAcoustic NerveGlossopharyngeal NerveVagus NerveAccessory NerveHypoglossal NerveSpinal MeningesCervical Spinal CordThoracic Spinal CordLumbar Spinal CordCharacter 5Approach0 Open3 Percutaneous4 Percutaneous EndoscopicCharacter 6DeviceCharacter 7QualifierZ No QualifierZ No DeviceAHA: 00Q20ZZ - 3Q 2013, 25New and Revised CodesNCNon-covered 2020 DecisionHealth 2021 ICD-10-PCS ExpertLCLimited Coverage Male FemaleAHA AHA Coding Clinic125
Central Nervous System and Cranial Nerves 00R–00UCentral Nervous System and Cranial Nerves 00R–00UICD-10-PCS Tabular List to Procedures0 Medical and Surgical0 Central Nervous System and Cranial NervesR Replacement: Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part126FGHJKLMNPQRSTCharacter 4Body PartCerebral MeningesDura MaterCerebral VentricleOlfactory NerveOptic NerveOculomotor NerveTrochlear NerveTrigeminal NerveAbducens NerveFacial NerveAcoustic NerveGlossopharyngeal NerveVagus NerveAccessory NerveHypoglossal NerveSpinal MeningesCharacter 5Approach0 Open4 Percutaneous EndoscopicCharacter 6Device7 Autologous Tissue SubstituteJ Synthetic SubstituteK Nonautologous Tissue SubstituteCharacter 7QualifierZ No Qualifier0 Medical and Surgical0 Central Nervous System and Cranial NervesS Reposition: Moving to its normal location, or other suitable location, all or a portion of a body partFGHJKLMNPQRSWXYCharacter 4Body PartOlfactory NerveOptic NerveOculomotor NerveTrochlear NerveTrigeminal NerveAbducens NerveFacial NerveAcoustic NerveGlossopharyngeal NerveVagus NerveAccessory NerveHypoglossal NerveCervical Spinal CordThoracic Spinal CordLumbar Spinal CordCharacter 5Approach0 Open3 Percutaneous4 Percutaneous EndoscopicCharacter 6DeviceCharacter 7QualifierZ No QualifierCharacter 6DeviceCharacter 7QualifierZ No QualifierZ No Device0 Medical and Surgical0 Central Nervous System and Cranial NervesT Resection: Cutting out or off, without replacement, all of a body partCharacter 4Body Part7 Cerebral HemisphereCharacter 5Approach0 Open3 Percutaneous4 Percutaneous EndoscopicZ No Device0 Medical and Surgical0 Central Nervous System and Cranial NervesU Supplement: Putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part126FGHJKLMNPQRSTCharacter 4Body PartCerebral MeningesDura MaterCerebral VentricleOlfactory NerveOptic NerveOculomotor NerveTrochlear NerveTrigeminal NerveAbducens NerveFacial NerveAcoustic NerveGlossopharyngeal NerveVagus NerveAccessory NerveHypoglossal NerveSpinal MeningesCharacter 5Approach0 Open3 Percutaneous4 Percutaneous EndoscopicCharacter 6Device7 Autologous Tissue SubstituteJ Synthetic SubstituteK Nonautologous Tissue SubstituteCharacter 7QualifierZ No QualifierAHA: 00U20KZ - 1Q 2018, 7, 3Q 2017, 10New and Revised Codes126NCNon-coveredLCLimited Coverage Male FemaleAHA AHA Coding Clinic2021 ICD-10-PCS Expert 2020 DecisionHealth
ICD-10-PCS Tabular List to ProceduresCentral Nervous System and Cranial Nerves 00W–00XCentral Nervous System and Cranial Nerves 00W–00X0 Medical and Surgical0 Central Nervous System and Cranial NervesW Revision: Correcting, to the extent possible, a portion of a malfunctioning device or the position of a displaced deviceCharacter 4Body PartCharacter 5Approach0 BrainV Spinal Cord0 Open3 Percutaneous4 Percutaneous Endoscopic0237JKMYCharacter 6DeviceDrainage DeviceMonitoring DeviceInfusion DeviceAutologous Tissue SubstituteSynthetic SubstituteNonautologous Tissue SubstituteNeurostimulator LeadOther DeviceCharacter 7QualifierZ No Qualifier0 BrainV Spinal CordX External0237JKMDrainage DeviceMonitoring DeviceInfusion DeviceAutologous Tissue SubstituteSynthetic SubstituteNonautologous Tissue SubstituteNeurostimulator LeadZ No Qualifier6 Cerebral VentricleU Spinal Canal0 Open3 Percutaneous4 Percutaneous Endoscopic023JMYDrainage DeviceMonitoring DeviceInfusion DeviceSynthetic SubstituteNeurostimulator LeadOther DeviceZ No Qualifier6 Cerebral VentricleU Spinal CanalX External023JMDrainage DeviceMonitoring DeviceInfusion DeviceSynthetic SubstituteNeurostimulator LeadZ No QualifierE Cranial Nerve0 Open3 Percutaneous4 Percutaneous Endoscopic0237MYDrainage DeviceMonitoring DeviceInfusion DeviceAutologous Tissue SubstituteNeurostimulator LeadOther DeviceZ No QualifierE Cranial NerveX External0237MDrainage DeviceMonitoring DeviceInfusion DeviceAutologous Tissue SubstituteNeurostimulator LeadZ No Qualifier0 Medical and Surgical0 Central Nervous System and Cranial NervesX Transfer: Moving, 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 partFGHJKLMNPQRSCharacter 4Body PartOlfactory NerveOptic NerveOculomotor NerveTrochlear NerveTrigeminal NerveAbducens NerveFacial NerveAcoustic NerveGlossopharyngeal NerveVagus NerveAccessory NerveHypoglossal NerveCharacter 5Approach0 Open4 Percutaneous EndoscopicNew and Revised CodesNCNon-covered 2020 DecisionHealth 2021 ICD-10-PCS ExpertLCLimited CoverageCharacter 6DeviceZ No DeviceFGHJKLMNPQRS Male FemaleCharacter 7QualifierOlfactory NerveOptic NerveOculomotor NerveTrochlear NerveTrigeminal NerveAbducens NerveFacial NerveAcoustic NerveGlossopharyngeal NerveVagus NerveAccessory NerveHypoglossal NerveAHA AHA Coding Clinic127
Peripheral Nervous System 012–018Peripheral Nervous System 012–018ICD-10-PCS Tabular List to ProceduresPeripheral Nervous System 012–01X0 Medical and Surgical1 Peripheral Nervous System2 Change: Taking 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 amucous membraneCharacter 4Body PartY Peripheral NerveCharacter 5ApproachX ExternalCharacter 6Device0 Drainage DeviceY Other DeviceCharacter 7QualifierZ No Qualifier0 Medical and Surgical1 Peripheral Nervous System5 Destruction: Physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent012345689ABCDFGHKLMNPQRCharacter 4Body PartCervical PlexusCervical NervePhrenic NerveBrachial PlexusUlnar NerveMedian NerveRadial NerveThoracic NerveLumbar PlexusLumbosacral PlexusLumbar NervePudendal NerveFemoral NerveSciatic NerveTibial NervePeroneal NerveHead and Neck Sympathetic NerveThoracic Sympathetic NerveAbdominal Sympathetic NerveLumbar Sympathetic NerveSacral Sympathetic NerveSacral PlexusSacral NerveCharacter 5Approach0 Open3 Percutaneous4 Percutaneous EndoscopicCharacter 6DeviceCharacter 7QualifierZ No QualifierZ No Device0 Medical and Surgical1 Peripheral Nervous System8 Division: Cutting into a body part, without draining fluids and/or gases from the body part, in order to separate or transect a body part012345689ABCDFGHKLMNPQRCharacter 4Body PartCervical PlexusCervical NervePhrenic NerveBrachial PlexusUlnar NerveMedian NerveRadial NerveThoracic NerveLumbar PlexusLumbosacral PlexusLumbar NervePudendal NerveFemoral NerveSciatic NerveTibial NervePeroneal NerveHead and Neck Sympathetic NerveThoracic Sympathetic NerveAbdominal Sympathetic NerveLumbar Sympathetic NerveSacral Sympathetic NerveSacral PlexusSacral NerveNew and Revised Codes128Character 5Approach0 Open3 Percutaneous4 Percutaneous EndoscopicNCNon-coveredLCLimited CoverageCharacter 6DeviceCharacter 7QualifierZ No QualifierZ No Device Male FemaleAHA AHA Coding Clinic2021 ICD-10-PCS Expert 2020 DecisionHealth
ICD-10-PCS Tabular List to Procedures 124 2021 Central Nervous System and Cranial Nerves 00K-00N Central Nervous System and Cranial Nerves 00K-00N
