Medical and Surgical Section Guidelines
B2. Body System
General guidelines
B2.1a
The procedure codes in Anatomical Regions, General, Anatomical Regions, Upper Extremities and Anatomical Regions, Lower Extremities can be used when the procedure is performed on an anatomical region rather than a specific body part, or on the rare occasion when no information is available to support assignment of a code to a specific body part. Examples: Chest tube drainage of the pleural cavity is coded to the root operation Drainage found in the body system Anatomical Regions, General. Suture repair of the abdominal wall is coded to the root operation Repair in the body system Anatomical Regions, General. Amputation of the foot is coded to the root operation Detachment in the body system Anatomical Regions, Lower Extremities.
B2.1b
Where the general body part values “upper” and “lower” are provided as an option in the Upper Arteries, Lower Arteries, Upper Veins, Lower Veins, Muscles and Tendons body systems, “upper” or “lower “specifies body parts located above or below the diaphragm respectively. Example: Vein body parts above the diaphragm are found in the Upper Veins body system; vein body parts below the diaphragm are found in the Lower Veins body system.
B3. Root Operation
General guidelines
B3.1a
In order to determine the appropriate root operation, the full definition of the root operation as contained in the PCS Tables must be applied.
B3.1b
Components of a procedure specified in the root operation definition or explanation as integral to that root operation are not coded separately. Procedural steps necessary to reach the operative site and close the operative site, including anastomosis of a tubular body part, are also not coded separately. Examples: Resection of a joint as part of a joint replacement procedure is included in the root operation definition of Replacement and is not coded separately. Laparotomy performed to reach the site of an open liver biopsy is not coded separately. In a resection of sigmoid colon with anastomosis of descending colon to rectum, the anastomosis is not coded separately. Multiple procedures
B3.2
During the same operative episode, multiple procedures are coded if: a. The same root operation is performed on different body parts as defined by distinct values of the body part character. Examples: Diagnostic excision of liver and pancreas are coded separately. Excision of lesion in the ascending colon and excision of lesion in the transverse colon are coded separately. b. The same root operation is repeated in multiple body parts, and those body parts are separate and distinct body parts classified to a single ICD-10-PCS body part value. Examples: Excision of the sartorius muscle and excision of the gracilis muscle are both included in the upper leg muscle body part value, and multiple procedures are coded. Extraction of multiple toenails are coded separately. c. Multiple root operations with distinct objectives are performed on the same body part. Example: Destruction of sigmoid lesion and bypass of sigmoid colon are coded separately. d. The intended root operation is attempted using one approach but is converted to a different approach. Example: Laparoscopic cholecystectomy converted to an open cholecystectomy is coded as percutaneous endoscopic Inspection and open Resection. Discontinued or incomplete procedures
B3.3
If the intended procedure is discontinued or otherwise not completed, code the procedure to the root operation performed. If a procedure is discontinued before any other root operation is performed, code the root operation Inspection of the body part or anatomical region inspected. Example: A planned aortic valve replacement procedure is discontinued after the initial thoracotomy and before any incision is made in the heart muscle, when the patient becomes hemodynamically unstable. This procedure is coded as an open Inspection of the mediastinum. Biopsy procedures
B3.4a
Biopsy procedures are coded using the root operations Excision, Extraction, or Drainage and the qualifier Diagnostic. Examples: Fine needle aspiration biopsy of fluid in the lung is coded to the root operation Drainage with the qualifier Diagnostic. Biopsy of bone marrow is coded to the root operation Extraction with the qualifier Diagnostic. Lymph node sampling for biopsy is coded to the root operation Excision with the qualifier Diagnostic. Biopsy followed by more definitive treatment
B3.4b
If a diagnostic Excision, Extraction, or Drainage procedure (biopsy) is followed by a more definitive procedure, such as Destruction, Excision or Resection at the same procedure site, both the biopsy and the more definitive treatment are coded. Example: Biopsy of breast followed by partial mastectomy at the same procedure site, both the biopsy and the partial mastectomy procedure are coded. Overlapping body layers
B3.5
If root operations such as Excision, Extraction, Repair or Inspection are performed on overlapping layers of the musculoskeletal system, the body part specifying the deepest layer is coded. Example: Excisional debridement that includes skin and subcutaneous tissue and muscle is coded to the muscle body part. Bypass procedures
B3.6a
Bypass procedures are coded by identifying the body part bypassed “from” and the body part bypassed “to.” The fourth character body part specifies the body part bypassed from, and the qualifier specifies the body part bypassed to. Example: Bypass from stomach to jejunum, stomach is the body part and jejunum is the qualifier.
B3.6b
Coronary artery bypass procedures are coded differently than other bypass procedures as described in the previous guideline. Rather than identifying the body part bypassed from, the body part identifies the number of coronary arteries bypassed to, and the qualifier specifies the vessel bypassed from. Example: Aortocoronary artery bypass of the left anterior descending coronary artery and the obtuse marginal coronary artery is classified in the body part axis of classification as two coronary arteries, and the qualifier specifies the aorta as the body part bypassed from.
B3.6c
If multiple coronary arteries are bypassed, a separate procedure is coded for each coronary artery that uses a different device and/or qualifier. Example: Aortocoronary artery bypass and internal mammary coronary artery bypass are coded separately. Control vs. more specific root operations
B3.7
The root operation Control is defined as, “Stopping, or attempting to stop, postprocedural or other acute bleeding.” Control is the root operation coded when the procedure performed to achieve hemostasis, beyond what would be considered integral to a procedure, utilizes techniques (e.g., cautery, application of substances or pressure, suturing or ligation or clipping of bleeding points at the site) that are not described by a more specific root operation definition, such as Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection. If a more specific root operation definition applies to the procedure performed, then the more specific root operation is coded instead of Control. Example: Silver nitrate cautery to treat acute nasal bleeding is coded to the root operation Control. Example: Liquid embolization of the right internal iliac artery to treat acute hematoma by stopping blood flow is coded to the root operation Occlusion. Example: Suctioning of residual blood to achieve hemostasis during a transbronchial cryobiopsy is considered integral to the cryobiopsy procedure and is not coded separately. Excision vs. Resection
B3.8
PCS contains specific body parts for anatomical subdivisions of a body part, such as lobes of the lungs or liver and regions of the intestine. Resection of the specific body part is coded whenever all of the body part is cut out or off, rather than coding Excision of a less specific body part. Example: Left upper lung lobectomy is coded to Resection of Upper Lung Lobe, Left rather than Excision of Lung, Left. Excision for graft
B3.9
If an autograft is obtained from a different procedure site in order to complete the objective of the procedure, a separate procedure is coded, except when the seventh character qualifier value in the ICD-10-PCS table fully specifies the site from which the autograft was obtained. Examples: Coronary bypass with excision of saphenous vein graft, excision of saphenous vein is coded separately. Replacement of breast with autologous deep inferior epigastric artery perforator (DIEP) flap, excision of the DIEP flap is not coded separately. The seventh character qualifier value Deep Inferior Epigastric Artery Perforator Flap in the Replacement table fully specifies the site of the autograft harvest. Fusion procedures of the spine
B3.10a
The body part coded for a spinal vertebral joint(s) rendered immobile by a spinal fusion procedure is classified by the level of the spine (e.g., thoracic). There are distinct body part values for a single vertebral joint and for multiple vertebral joints at each spinal level. Example: Body part values specify Lumbar Vertebral Joint, Lumbar Vertebral Joints, 2 or More and Lumbosacral Vertebral Joint.
B3.10b
If multiple vertebral joints are fused, a separate procedure is coded for each vertebral joint that uses a different device and/or qualifier. Example: Fusion of lumbar vertebral joint, posterior approach, anterior column and fusion of lumbar vertebral joint, posterior approach, posterior column are coded separately.
B3.10c
Combinations of devices and materials are often used on a vertebral joint to render the joint immobile. When combinations of devices are used on the same vertebral joint, the device value coded for the procedure is as follows:
- If an interbody fusion device is used to render the joint immobile (containing bone graft or bone graft substitute), the procedure is coded with the device value Interbody Fusion Device
- If bone graft is the only device used to render the joint immobile, the procedure is coded with the device value Nonautologous Tissue Substitute or Autologous Tissue Substitute
- If a mixture of autologous and nonautologous bone graft (with or without biological or synthetic extenders or binders) is used to render the joint immobile, code the procedure with the device value Autologous Tissue Substitute Examples: Fusion of a vertebral joint using a cage style interbody fusion device containing morsellized bone graft is coded to the device Interbody Fusion Device. Fusion of a vertebral joint using a bone dowel interbody fusion device made of cadaver bone and packed with a mixture of local morsellized bone and demineralized bone matrix is coded to the device Interbody Fusion Device. Fusion of a vertebral joint using both autologous bone graft and bone bank bone graft is coded to the device Autologous Tissue Substitute. Inspection procedures
B3.11a
Inspection of a body part(s) performed in order to achieve the objective of a procedure is not coded separately. Example: Fiberoptic bronchoscopy performed for irrigation of bronchus, only the irrigation procedure is coded.
B3.11b
If multiple tubular body parts are inspected, the most distal body part (the body part furthest from the starting point of the inspection) is coded. If multiple non-tubular body parts in a region are inspected, the body part that specifies the entire area inspected is coded. Examples: Cystoureteroscopy with inspection of bladder and ureters is coded to the ureter body part value. Exploratory laparotomy with general inspection of abdominal contents is coded to the peritoneal cavity body part value.
B3.11c
When both an Inspection procedure and another procedure are performed on the same body part during the same episode, if the Inspection procedure is performed using a different approach than the other procedure, the Inspection procedure is coded separately. Example: Endoscopic Inspection of the duodenum is coded separately when open Excision of the duodenum is performed during the same procedural episode. Occlusion vs. Restriction for vessel embolization procedures
B3.12
If the objective of an embolization procedure is to completely close a vessel, the root operation Occlusion is coded. If the objective of an embolization procedure is to narrow the lumen of a vessel, the root operation Restriction is coded. Examples: Tumor embolization is coded to the root operation Occlusion, because the objective of the procedure is to cut off the blood supply to the vessel. Embolization of a cerebral aneurysm is coded to the root operation Restriction, because the objective of the procedure is not to close off the vessel entirely, but to narrow the lumen of the vessel at the site of the aneurysm where it is abnormally wide. Release procedures
B3.13
In the root operation Release, the body part value coded is the body part being freed and not the tissue being manipulated or cut to free the body part. Example: Lysis of intestinal adhesions is coded to the specific intestine body part value. Release vs. Division
B3.14
If the sole objective of the procedure is freeing a body part without cutting the body part, the root operation is Release. If the sole objective of the procedure is separating or transecting a body part, the root operation is Division. Examples: Freeing a nerve root from surrounding scar tissue to relieve pain is coded to the root operation Release. Severing a nerve root to relieve pain is coded to the root operation Division. Reposition for fracture treatment
B3.15
Reduction of a displaced fracture is coded to the root operation Reposition and the application of a cast or splint in conjunction with the Reposition procedure is not coded separately. Treatment of a nondisplaced fracture is coded to the procedure performed. Examples: Casting of a nondisplaced fracture is coded to the root operation Immobilization in the Placement section. Putting a pin in a nondisplaced fracture is coded to the root operation Insertion. 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. Transfer procedures using multiple tissue layers
B3.17
The root operation Transfer contains qualifiers that can be used to specify when a transfer flap is composed of more than one tissue layer, such as a musculocutaneous flap. For procedures involving transfer of multiple tissue layers including skin, subcutaneous tissue, fascia or muscle, the procedure is coded to the body part value that describes the deepest tissue layer in the flap, and the qualifier can be used to describe the other tissue layer(s) in the transfer flap. Example: A musculocutaneous flap transfer is coded to the appropriate body part value in the body system Muscles, and the qualifier is used to describe the additional tissue layer(s) in the transfer flap. Excision/Resection followed by replacement
B3.18
If an excision or resection of a body part is followed by a replacement procedure, code both procedures to identify each distinct objective, except when the excision or resection is considered integral and preparatory for the replacement procedure. Examples: Mastectomy followed by reconstruction, both resection and replacement of the breast are coded to fully capture the distinct objectives of the procedures performed. Maxillectomy with obturator reconstruction, both excision and replacement of the maxilla are coded to fully capture the distinct objectives of the procedures performed. Excisional debridement of tendon with skin graft, both the excision of the tendon and the replacement of the skin with a graft are coded to fully capture the distinct objectives of the procedures performed. Esophagectomy followed by reconstruction with colonic interposition, both the resection and the transfer of the large intestine to function as the esophagus are coded to fully capture the distinct objectives of the procedures performed. Examples: Resection of a joint as part of a joint replacement procedure is considered integral and preparatory for the replacement of the joint and the resection is not coded separately. Resection of a valve as part of a valve replacement procedure is considered integral and preparatory for the valve replacement and the resection is not coded separately. Detachment procedures of extremities
B3.19
The root operation Detachment contains qualifiers that can be used to specify the level where the extremity was amputated. These qualifiers are dependent on the body part value in the “upper extremities” and “lower extremities” body systems. For procedures involving the detachment of all or part of the upper or lower extremities, the procedure is coded to the body part value that describes the site of the detachment. Example: An amputation at the proximal portion of the shaft of the tibia and fibula is coded to the Lower leg body part value in the body system Anatomical Regions, Lower Extremities, and the qualifier High is used to specify the level where the extremity was detached. The following definitions were developed for the Detachment qualifiers Body Part Qualifier Definition Upper arm and upper leg High: Amputation at the proximal portion of the shaft of the humerus or femur Mid: Amputation at the middle portion of the shaft of the humerus or femur Low: Amputation at the distal portion of the shaft of the humerus or femur Lower arm and lower leg High: Amputation at the proximal portion of the shaft of the radius/ulna or tibia/fibula Mid: Amputation at the middle portion of the shaft of the radius/ulna or tibia/fibula Low: Amputation at the distal portion of the shaft of the radius/ulna or tibia/fibula Hand and Foot Complete* Complete 1st Ray Complete 2nd Ray Complete 3rd Ray Complete 4th Ray Complete 5th Ray Partial 1st Ray B Partial 2nd Ray C Partial 3rd Ray D Partial 4th Ray F Partial 5th Ray Thumb, finger, or toe Complete: Amputation at the metacarpophalangeal/metatarsal-phalangeal joint High: Amputation anywhere along the proximal phalanx Mid: Amputation through the proximal interphalangeal joint or anywhere along the middle phalanx Low: Amputation through the distal interphalangeal joint or anywhere along the distal phalanx *When coding amputation of Hand and Foot, the following definitions are followed:
- Complete: Amputation through the carpometacarpal joint of the hand, or through the tarsal-metatarsal joint of the foot.
- Partial: Amputation anywhere along the shaft or head of the metacarpal bone of the hand, or of the metatarsal bone of the foot.
B4. Body Part
General guidelines
B4.1a
If a procedure is performed on a portion of a body part that does not have a separate body part value, code the body part value corresponding to the whole body part. Example: A procedure performed on the alveolar process of the mandible is coded to the mandible body part.
B4.1b
If the prefix “peri” is combined with a body part to identify the site of the procedure, and the site of the procedure is not further specified, then the procedure is coded to the body part named. This guideline applies only when a more specific body part value is not available. Examples: A procedure site identified as perirenal is coded to the kidney body part when the site of the procedure is not further specified. A procedure site described in the documentation as peri-urethral, and the documentation also indicates that it is the vulvar tissue and not the urethral tissue that is the site of the procedure, then the procedure is coded to the vulva body part. A procedure site documented as involving the periosteum is coded to the corresponding bone body part.
B4.1c
If a single vascular procedure is performed on a continuous section of an arterial or venous body part, code the body part value corresponding to the anatomically most proximal (closest to the heart) portion of the arterial or venous body part. Example: A procedure performed on a continuous section of artery from the femoral artery to the external iliac artery with the point of entry at the femoral artery is coded to the external iliac body part. A procedure performed on a continuous section of artery from the femoral artery to the external iliac artery with the point of entry at the external iliac artery is also coded to the external iliac artery body part. Branches of body parts
B4.2
Where a specific branch of a body part does not have its own body part value in PCS, the body part is typically coded to the closest proximal branch that has a specific body part value. In the cardiovascular body systems, if a general body part is available in the correct root operation table, and coding to a proximal branch would require assigning a code in a different body system, the procedure is coded using the general body part value. Examples: A procedure performed on the mandibular branch of the trigeminal nerve is coded to the trigeminal nerve body part value. Occlusion of the bronchial artery is coded to the body part value Upper Artery in the body system Upper Arteries, and not to the body part value Thoracic Aorta, Descending in the body system Heart and Great Vessels. Bilateral body part values
B4.3
Bilateral body part values are available for a limited number of body parts. If the identical procedure is performed on contralateral body parts, and a bilateral body part value exists for that body part, a single procedure is coded using the bilateral body part value. If no bilateral body part value exists, each procedure is coded separately using the appropriate body part value. Examples: The identical procedure performed on both fallopian tubes is coded once using the body part value Fallopian Tube, Bilateral. The identical procedure performed on both knee joints is coded twice using the body part values Knee Joint, Right and Knee Joint, Left. Coronary arteries
B4.4
The coronary arteries are classified as a single body part that is further specified by the number of arteries treated. One procedure code specifying multiple arteries is used when the same procedure is performed, including the same device and qualifier values. Examples: Angioplasty of two distinct coronary arteries with placement of two stents is coded as Dilation of Coronary Artery, Two Arteries with Two Intraluminal Devices. Angioplasty of two distinct coronary arteries, one with stent placed and one without, is coded separately as Dilation of Coronary Artery, One Artery with Intraluminal Device, and Dilation of Coronary Artery, One Artery with no device. Tendons, ligaments, bursae and fascia near a joint
B4.5
Procedures performed on tendons, ligaments, bursae and fascia supporting a joint are coded to the body part in the respective body system that is the focus of the procedure. Procedures performed on joint structures themselves are coded to the body part in the joint body systems. Examples: Repair of the anterior cruciate ligament of the knee is coded to the knee bursa and ligament body part in the bursae and ligaments body system. Knee arthroscopy with shaving of articular cartilage is coded to the knee joint body part in the Lower Joints body system. Skin, subcutaneous tissue and fascia overlying a joint
B4.6
If a procedure is performed on the skin, subcutaneous tissue or fascia overlying a joint, the procedure is coded to the following body part:
- Shoulder is coded to Upper Arm
- Elbow is coded to Lower Arm
- Wrist is coded to Lower Arm
- Hip is coded to Upper Leg
- Knee is coded to Lower Leg
- Ankle is coded to Foot Fingers and toes
B4.7
If a body system does not contain a separate body part value for fingers, procedures performed on the fingers are coded to the body part value for the hand. If a body system does not contain a separate body part value for toes, procedures performed on the toes are coded to the body part value for the foot. Example: Excision of finger muscle is coded to one of the hand muscle body part values in the Muscles body system. Upper and lower intestinal tract
B4.8
In the Gastrointestinal body system, the general body part values Upper Intestinal Tract and Lower Intestinal Tract are provided as an option for the root operations such as Change, Insertion, Inspection, Removal and Revision. Upper Intestinal Tract includes the portion of the gastrointestinal tract from the esophagus down to and including the duodenum, and Lower Intestinal Tract includes the portion of the gastrointestinal tract from the jejunum down to and including the rectum and anus. Example: In the root operation Change table, change of a device in the jejunum is coded using the body part Lower Intestinal Tract.
B5. Approach
Open approach with percutaneous endoscopic assistance
B5.2a
Procedures performed using the open approach with percutaneous endoscopic assistance are coded to the approach Open. Example: Laparoscopic-assisted sigmoidectomy is coded to the approach Open. Percutaneous endoscopic approach with hand-assistance or extension of incision
B5.2b
Procedures performed using the percutaneous endoscopic approach with hand-assistance, or with an incision or extension of an incision to assist in the removal of all or a portion of a body part, or to anastomose a tubular body part with or without the temporary exteriorization of a body structure, are coded to the approach value Percutaneous Endoscopic. Examples: Hand-assisted laparoscopic sigmoid colon resection with exteriorization of a segment of the colon for removal of specimen with return of colon back into abdominal cavity is coded to the approach value percutaneous endoscopic. Laparoscopic sigmoid colectomy with extension of stapling port for removal of specimen and direct anastomosis is coded to the approach value percutaneous endoscopic. Laparoscopic nephrectomy with midline incision for removing the resected kidney is coded to the approach value percutaneous endoscopic. Robotic-assisted laparoscopic prostatectomy with extension of incision for removal of the resected prostate is coded to the approach value percutaneous endoscopic. External approach
B5.3a
Procedures performed within an orifice on structures that are visible without the aid of any instrumentation are coded to the approach External. Example: Resection of tonsils is coded to the approach External.
B5.3b
Procedures performed indirectly by the application of external force through the intervening body layers are coded to the approach External. Example: Closed reduction of fracture is coded to the approach External. Percutaneous procedure via device
B5.4
Procedures performed percutaneously via a device placed for the procedure are coded to the approach Percutaneous. Example: Fragmentation of kidney stone performed via percutaneous nephrostomy is coded to the approach Percutaneous.
B6. Device
General guidelines
B6.1a
A device is coded only if a device remains after the procedure is completed. If no device remains, the device value No Device is coded. In limited root operations, the classification provides the qualifier values Temporary and Intraoperative, for specific procedures involving clinically significant devices, where the purpose of the device is to be utilized for a brief duration during the procedure or current inpatient stay. If a device that is intended to remain after the procedure is completed requires removal before the end of the operative episode in which it was inserted, both the insertion and removal of the device should be coded.
B6.1b
Materials such as sutures, ligatures, radiological markers and temporary post-operative wound drains are considered integral to the performance of a procedure and are not coded as devices.
B6.1c
Procedures performed on a device only and not on a body part are specified in the root operations Change, Irrigation, Removal and Revision, and are coded to the procedure performed. Example: Irrigation of percutaneous nephrostomy tube is coded to the root operation Irrigation of indwelling device in the Administration section. Drainage device
B6.2
A separate procedure to put in a drainage device is coded to the root operation Drainage with the device value Drainage Device.