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Coding I Test 3

Terms in this set (36)

PCS code characters
7 characters
ALL 7 must be specified
ICD-10-PCS Code Structure and Format
1 Section
2 Body System
3 Root Operation
4 Body Part
5 Approach
6 Device
7 Qualifier
SECTIONS
Med & Surg
Obstetrics
Placement
Administration
BODY SYSTEMS
can be single value like Respiratory System
or multiple values like Musculoskeletal = Muscles, Tendons, Bursae, Ligaments
ROOT OPERATION
what the procedure is trying to accomplish
alteration
modifying the natural anatomic structure of a body part without affecting function of the body part

(improve appearance)

face lift, breast augmentation
bypass
altering the route of passage of the contents of a tubular body part

(rerouting contents of a body part to a downstream area of the normal route)

coronary artery bypass, colostomy formation
change
taking out or off a device from a body part and putting back an identical or similar route

(all CHANGE procedures are coded using EXTERNAL approach)

urinary catheter change, gastrostomy tube change
control
stopping, or attempting to stop, postprocedural or other acute bleeding

(site of bleeding is coded as an anatomical region and not a specific body part)

post-prostatectomy hemmohage, intracranial subdural hemmorhage
creation
putting in or on biological or synthetic material to form a new body part that to the extent possible replicates the anatomic structure or function of an absent body part

(used for gender reassignment surgery and corrective procedures in congenital abnormalities)

vagina for a male, left and right atrioventricular valve from common atrioventricular valve
destruction
physical eradication of of all or a portion of a body part by the direct use of energy, force, or a destructive agent

(none of the body part is physically taken out)

fulguration of rectal polyp, cautery of skin lesion
detachment
cutting off all or a portion of the upper or lower extremities

(the body part value is the site of the detachment, with a qualifier if applicable to specify the level where the extremity was detached)

below knee amputation, disarticulation of shoulder
dilation
expanding an orifice or the lumen of a tubular body part

(can be a natural or artificially created)

percutaneous transluminal angioplasty, internal urethrotomy
division
cutting into a body part, without draining fluids and/or gasses from the body part, in order to separate or transect a body part

(all or a portion of the body part is separated into 2 or more portions)

spinal cordotomy, osteotomy
drainage
taking or letting out fluids and/or gasses from a body part

(qualifier DIAGNOSTIC is used to identify drainage procedures that are biopsies)

thoracentesis, incision and drainage
excision
cutting out or off, without replacement, a portion of a body part

(qualifier DIAGNOSTIC is used to identify excision procedures that are biopsies)

partial nephrectomy, liver biopsy
extripation
taking or cutting out solid matter from a body part

(may be an abnormal byproduct of abiological function or a foreign body. May be imbedded in a body part or in the lumen of a tubular body. Solid matter may or may not have been previously broken into pieces.)

thrombectomy, choledocholithotomy
extraction
pulling or stripping out or off all or a portion of a body part by the use of force

(DIAGNOSTIC qualifier used to identify extractions that are biopsies)

dilation and curettage, vein stripping
fragmentation
breaking solid matter in a body part into pieces

(physical force applied directly or indirectly to break solid matter into pieces. The solid matter may be an abnormal byproduct of a biological function or a foreign body. The pieces of solid matter are not taken out)

extracorporeal shockwave lithotripsy, tranurethral lithotripsy
fusion
joining together portions of an articular body part rendering the articular body part immobile

(the body part is joined together by fixation device, bone graft, or other means)

spinal fusion, ankle arthrodesis
insertion
putting in a nonbiological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of the body part

insertion of radioactive implant, insertion of central venous catheter
inspection
visually and/or manually exploring a body part

(visual exploration may be performed with or without optical instrumentation. Manual exploration may be performed directly or through intervening body layers)

diagnostic arthroscopy, exploratory laparotomy
map
locating the route of passage of electrical impulses and/or locating functional areas in a body part

(applicable only to the cardiac conduction mechanism and the central nervous system)

cardiac mapping, cortical mapping
occlusion
completely closing an orifice or lumen of atubular body part

(the orifice can be a natural orifice or an artificially created orifice)

fallopian tube ligation, ligation of inferior vena cava
reattachment
putting back in or on all or a portion of a separated body part to its normal location or other suitable location

(vascular circulation and nervous pathways may or may not be reestablished)

reattachment of hand, reattachment of avulsed kidney
release
freeing a body part from an abnormal physical constraint by cutting or by use of force

(some of the restraining tissue may be taken out but none of the body part is taken out)

adhesiolysis, carpal tunnel release
removal
taking out or off a device from a body part

(if a device is taken out and a similar device put in without cutting or puncturing the skin or mucous membrane, the procedure is coded to root operation CHANGE. Otherwise, the procedure for taking out a device is coded to REMOVAL)

drainage tube removal,cardiac pacemaker removal
repair
restoring, to the extent possible, a body part to its normal anatomic structure and function

(used only when the method to accomplish the repair is not one of the other root operations)

colostomy takedown, suture of laceration
replacement
putting in or on a biological or synthetic material that physically takes the place and/or function of all or a portion of a body part

(the body part may have been taken out, physically eradicated, or rendered nonfunctional during the REPLACEMENT procedure. A REMOVAL procedure is coded for taking out the device used in a previous replacement procedure)

total hip replacement, bone graft, free skin graft
reposition
moving to its normal location, or other suitable location, all or a portion of a body part

(the body part is moved to a new location from an abnormal location where it is not functioning correctly. The body part may or may not be cut out or off to be moved to the new location)

reposition of undescended testicle, fracture reduction
resection
cutting out or off, without replacement, all of a body part

total nephrectomy, total lobectomy of lung
restriction
partially closing an orifice or the lumen of a tubular body part

(the orifice can be a naturally orifice or an artificially created orifice)

esophagogastric fundoplication, cervical cerclage
revision
correcting, to the extent possible, a portion of a malfunctioning devise or the position of a displaced device

(revision can include correcting a malfunctioning or displaced device by taking out or putting in components of the device such as a screw or pin)

adjustment of position of pacemaker lead, recementing of hip prothesis
supplement
putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part

(the biological material is non-living, or is living and from the same individual. The body part may have been previously replaced, and the SUPPLEMENT procedure is performed to physically reinforce and/or augment the function of the replaced body part)

heriorrhaphy using mesh, free nerve graft, mitral valve ring annuloplasty, put a new acetabular liner in a previous hip replacement
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 part

(the body part transferred remains connected to its vascular and nervous supply)

tendon transfer, skin pedicle flap transfer
transplantation
putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part

(the native body part may or may not be taken out, and the transplanted body part may take over all or a portion of its function)

kidney transplant, heart transplant
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