General Coding Guidelines for Other Medical- and Surgical-Related Procedures and Ancillary Procedures

Learning Objectives

1. Apply the conventions and ICD-10-PCS Coding Guidelines

2. Define the root operations/types for each section of ICD-10-PCS

3. Define the approaches for each section of ICD-10-PCS

4. Assign procedure codes using ICD-10-PCS

Abbreviations/Acronyms

CT computerized tomography

ECMO extracorporeal membrane oxygenation

ECT electroconvulsive therapy

ICD-10-PCS International Classification of Diseases, 10th Revision, Procedure Coding System

MRI magnetic resonance imaging

PET positron emission tomography

ICD-10-PCS Coding Guidelines (2013)

Please refer to the companion Evolve website for the most current guidelines.

Transplantation vs. Administration

B3.16 Putting in a mature and functioning living body part taken from another individual or animal is coded to the root operation Transplantation. Putting in autologous or nonautologous cells is coded to the Administration section.
Example: Putting in autologous or nonautologous bone marrow, pancreatic islet cells or stem cells is coded to the Administration section.

Example

Nonautologous bone marrow transplant via central venous line in patient with multiple myeloma, C90.00, 30243G1.

Obstetric Section Guidelines (section 1)
C. Obstetrics Section
Products of conception

C1 Procedures performed on the products of conception are coded to the Obstetrics section. Procedures performed on the pregnant female other than the products of conception are coded to the appropriate root operation in the Medical and Surgical section.
Example: Amniocentesis is coded to the products of conception body part in the Obstetrics section. Repair of obstetric urethral laceration is coded to the urethra body part in the Medical and Surgical section.

Example

Amniocentesis was performed to screen for genetic and chromosomal abnormalities, Z13.79, 10903ZU.

Procedures following delivery or abortion

C2 Procedures performed following a delivery or abortion for curettage of the endometrium or evacuation of retained products of conception are all coded in the Obstetrics section, to the root operation Extraction and the body part Products of Conception, Retained. Diagnostic or therapeutic dilation and curettage performed during times other than the postpartum or post-abortion period are all coded in the Medical and Surgical section, to the root operation Extraction and the body part Endometrium.

Example

D&C for retained products of conception following a spontaneous abortion at 8 weeks’ gestation, O03.4, Z3A.08 10D17ZZ.

Other Medical- and Surgical-Related Procedures

The other medical- and surgical-related procedure sections of ICD-10-PCS include the following sections:

Section value	description
1	Obstetrics
2	Placement
3	Administration
4	Measurement and monitoring
5	Extracorporeal assistance and performance
6	Extracorporeal therapies
7	Osteopathic
8	Other procedures
9	Chiropractic

Obstetrics

Obstetrics include only those procedures that are performed on the products of conception. The term “products of conception” refers to all physical components of a pregnancy, including the fetus, amnion, umbilical cord, and placenta, regardless of gestational age. Procedures performed on a pregnant female other than on the products of conception are coded in the Medical and Surgical section. All ICD-10-PCS codes are seven characters, each character representing a particular aspect of the procedure. The meanings of the obstetric procedure characters are as follows:

CHARACTER	REPRESENTS
1	Section
2	Body system
3	Root operation
4	Body part
5	Approach
6	Device
7	Qualifier

Obstetric codes are found in Section 1, so they have a first-character value of 1. The second-character value for body system is Pregnancy. The third character identifies the root operation. There are a total of 12 root operations in the Obstetrics section. Ten of these are taken from the Medical and Surgical section and that includes:

CHARACTER	REPRESENTS
2	Change
9	Drainage
D	Extraction
H	Insertion
J	Inspection
P	Removal
Q	Repair
S	Reposition
T	Resection
Y	Transplantation

This section includes two additional root operations:

Abortion (A): artificially terminating a pregnancy

Delivery (E): assisting the passage of the products of conception from the genital canal

The fourth character classifies the body part. Body part values in this section are:

Products of conception

Products of conception, retained

Products of conception, ectopic

The fifth character identifies the approach; these are defined in the Medical and Surgical section. The sixth character is for the device. The seventh character identifies various qualifiers, such as type of extraction, type of cesarean section, and so on.

Example

Manually assisted delivery, 10E0XZZ

CHARACTER 1 SECTION	CHARACTER 2 BODY SYSTEM	CHARACTER 3 OPERATION	CHARACTER 4 BODY PART	CHARACTER 5 APPROACH	CHARACTER 6 DEVICE	CHARACTER 7 QUALIFIER
Obstetrics	Pregnancy	Delivery	Products of Conception	External	No Device	No Qualifier
1	0	E	0	X	Z	Z

The root operation, Delivery, applies only to manually-assisted, vaginal delivery and is defined as assisting the passage of the products of conception from the genital canal. Cesarean deliveries are coded in this section to the root operation extraction.

Exercise 7-1

Without the use of reference material, answer the following questions about ICD-10-PCS.

1. Obstetric procedures are any procedure performed on a pregnant woman.

A. True

B. False

2. In ICD-10-PCS, “abortion” is defined as “the spontaneous termination of a pregnancy.”

A. True

B. False

3. Low cervical cesarean section would be identified by the fifth character, the approach.

A. True

B. False

Placement

Placement codes include procedures for putting a device in or on a body region for the purpose of protection, immobilization, stretching, compression, or packing. All ICD-10-PCS codes are seven characters, each representing a particular aspect of the procedure. The meanings of the placement procedure characters are as follows:

CHARACTER	REPRESENTS
1	Section
2	Body system
3	Root operation
4	Body region
5	Approach
6	Device
7	Qualifier

Placement codes are found in Section 2, so they have a first-character value of 2. The second-character value, for body system, is either anatomical region or body orifice. The third character identifies the root operation. The root operations in the placement section include only those procedures performed without making an incision or a puncture. Two of these are taken from the Medical and Surgical section and that includes:

CHARACTER	REPRESENTS
0	Change
5	Removal

Section 2 includes five additional root operations:

Compression (1): putting pressure on a body region

Dressing (2): putting material on a body region for protection

Immobilization (3): limiting or preventing motion of a body region

Packing (4): putting material in a body region or orifice

Traction (6): exerting a pulling force on a body region in a distal direction

The fourth-character value classifies body region or natural orifice. The fifth-character value identifies the approach; and because all placement procedures are performed directly on the skin or mucous membranes, or indirectly by applying external force, the approach value is always X, for external. The sixth-character value classifies device. The seventh character is for a qualifier, but it is not used in the Placement section at this time, so the value is always no qualifier (Z).

Example

Cast to right lower arm, 2W3CX2Z

CHARACTER 1 SECTION	CHARACTER 2 BODY SYSTEM	CHARACTER 3 OPERATION	CHARACTER 4 BODY REGION	CHARACTER 5 APPROACH	CHARACTER 6 DEVICE	CHARACTER 7 QUALIFIER
Placement	Anatomical Region	Immobilization	Lower Arm, Right	External	Cast	No Qualifier
2	W	3	C	X	2	Z

Splints and braces that are placed in the inpatient setting are coded in this section. If a fitting for a device such as a splint or brace is performed in the rehabilitation setting, the codes from the F0D table are assigned.

Administration

Administration codes include procedures for putting in or on a therapeutic, prophylactic, protective, diagnostic, nutritional, or physiological substance. All ICD-10-PCS codes are seven characters, each representing a particular aspect of the procedure. The meanings of the administration procedure characters are as follows:

CHARACTER	REPRESENTS
1	Section
2	Body system
3	Root operation
4	Body system/region
5	Approach
6	Substance
7	Qualifier

Administration codes are found in Section 3, so they have a first-character value of 3. The second character has three values: physiological systems and anatomical regions, circulatory system, or indwelling device. The third-character value identifies the root operation. Section 3 has three root operations:

Introduction (0): putting in or on a therapeutic, diagnostic, nutritional, physiological, or prophylactic substance except blood or blood products

Irrigation (1): putting in or on a cleansing substance

Transfusion (2): putting in blood or blood products

The fourth-character value classifies body system/region. This identifies the site where the substance is administered. The fifth-character value identifies the approach, and each approach is defined in the Medical and Surgical section. Percutaneous is the approach for procedures that are introduced intradermally, subcutaneously, and intramuscularly (e.g., injections). The sixth-character value specifies the substance introduced. The seventh character is for a qualifier that indicates whether the substance used was autologous or nonautologous or to further specify the substance. Autologous means originating from the recipient, rather than from a donor, or transferred from the same individual’s body, (e.g., a skin graft is taken from one part of the body and transferred to another part of the body on the same individual).

Example

Administration of RBCs, nonautologous, via central vein, 30243N1

CHARACTER 1 SECTION	CHARACTER 2 BODY SYSTEM	CHARACTER 3 OPERATION	CHARACTER 4 BODY SYSTEM/REGION	CHARACTER 5 APPROACH	CHARACTER 6 SUBSTANCE	CHARACTER 7 QUALIFIER
Administration	Circulatory	Transfusion	Central Vein	Percutaneous	Red Blood Cells	Nonautologous
3	0	2	4	3	N	1

Exercise 7-2

Without the use of reference material, answer the following questions.

1. Irrigation is a root operation that is found in the Placement section.

A. True

B. False

2. Immobilization is limiting or preventing motion of a body region.

A. True

B. False

3. In the Administration section, Character 6 identifies the substance being introduced.

A. True

B. False

Measurement and Monitoring

Measurement and monitoring codes include procedures for determining the level of a physiological or physical function. All ICD-10-PCS codes are seven characters, each representing a particular aspect of the procedure. The meanings of the measuring and monitoring procedure characters are as follows:

CHARACTER	REPRESENTS
1	Section
2	Body system
3	Root operation
4	Body system
5	Approach
6	Function/Device
7	Qualifier

Measurement and monitoring codes are found in Section 4, so they have a first-character value of 4. The second character has two values, for either physiological systems or physiological devices. The third-character value identifies the root operation. Section 4 has two root operations:

Measurement (0): determining the level of a physiological or physical function at a point in time

Monitoring (1): determining the level of a physiological or physical function repetitively over a period of time

The fourth-character value identifies the body system being measured or monitored. The fifth-character value identifies the approach, and each is defined in the Medical and Surgical section. The sixth-character value specifies the physiological or physical function monitored. The seventh character is for a qualifier used to further specify the body part or a variation of the procedure performed.

Example

Holter monitoring, 4A12X45

CHARACTER 1 SECTION	CHARACTER 2 BODY SYSTEM	CHARACTER 3 OPERATION	CHARACTER 4 BODY SYSTEM	CHARACTER 5 APPROACH	CHARACTER 6 FUNCTION/DEVICE	CHARACTER 7 QUALIFIER
Measurement/Monitoring	Physiological Systems	Monitoring	Cardiac	External	Electrical Activity	Ambulatory
4	A	1	2	X	4	5

Extracorporeal Assistance and Performance

Extracorporeal assistance and performance codes are used when equipment outside of the body is used to assist or perform a physiological function. All ICD-10-PCS codes are seven characters, each representing a particular aspect of the procedure. The meanings of the extracorporeal assistance and performance procedure characters are as follows:

CHARACTER	REPRESENTS
1	Section
2	Body system
3	Root operation
4	Body system
5	Duration
6	Function
7	Qualifier

Extracorporeal assistance and performance codes are found in Section 5, so they have a first-character value of 5. The second-character value is for physiological systems. The third-character value identifies the root operation. The section has three root operations:

Assistance (0): taking over a portion of a physiological function by extracorporeal means such as intra-aortic balloon pump to support cardiac output.

Performance (1): completely taking over a physiological function by extracorporeal means such as total mechanical ventilation or cardiopulmonary bypass.

Restoration (2): returning, or attempting to return, a physiological function to its original state by extracorporeal means
Restoration defines only external cardioversion and defibrillation procedures. Failed cardioversion procedures are also included in the definition of restoration and are coded the same as successful procedures.

The fourth-character value classifies the body system to which the extracorporeal assistance or performance is applied. The fifth-character value identifies the duration of the procedure. The sixth-character value specifies the physiological function assisted or performed during the procedure. The seventh character is a qualifier that specifies the type of equipment used, if any.

Example

Mechanical ventilation, continuous for 48 hours, 5A1945Z

CHARACTER 1 SECTION	CHARACTER 2 BODY SYSTEM	CHARACTER 3 OPERATION	CHARACTER 4 BODY SYSTEM	CHARACTER 5 DURATION	CHARACTER 6 FUNCTION	CHARACTER 7 QUALIFIER
Extracorporeal Assistance or Performance	Physiological Systems	Performance	Respiratory	24-96 consecutive hours	Ventilation	No Qualifier
5	A	1	9	4	5	Z

Extracorporeal Therapies

Extracorporeal therapy codes are used when equipment outside of the body is used for a therapeutic purpose that does not involve the assistance or performance of a physiological function. All ICD-10-PCS codes are seven characters, each representing a particular aspect of the procedure. The meanings of the extracorporeal therapies procedure characters are as follows: