ICD-10-PCS
Procedure Coding Made Easy!
Barry Libman, MS, RHIA, CDIP, CCS, CCS-P
President, Barry Libman Inc.
President, Libman Education
AHIMA-approved ICD-10 Trainer
AHIMA ICD-10 Ambassador
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Timeline for Implementation of ICD-10
• The proposed compliance date for ICD-10CM/PCS is October 1, 2015
• No flexibility; no grace period; no allowance
for dual processing.
• May 21, 2014 = 498 days!
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ICD-10-PCS Essential Attributes
Completeness
- All substantially different procedures have a unique code
Expandability
- The structure of the system allows incorporation of new
procedures as unique codes
Standardized terminology
- Includes definitions of the terminology used. While the meaning
of specific words can vary in common usage, ICD-10-PCS
defines a single meaning for each term used in the system.
Multi-axial structure
- Each character has the same meaning within a section and
across sections to the extent possible
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Tools you will need
• ICD-10-PCS Code Set
- Body Part Key
- Device Key
- Device Aggregation Table
• ICD-10-PCS Coding Guidelines
• ICD-10-PCS Reference Manual (CMS)
• Coding Clinic for ICD-10-CM/PCS
• ICD-10CM and ICD-10-PCS Coding Handbook With
Answers, 2013 Revised Edition (AHA Press)
• ICD-10-PCS: An Applied Approach (AHIMA)
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ICD-10-PCS Code Structure
Codes are comprised of seven characters
34 possible values for each character
- Digits 0-9
- Letters A-H, J-N, P-Z
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ICD-10-PCS Code Format
The main section of ICD-10-PCS, the medical and surgical
section, has the following meanings for the seven
characters:
1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
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1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Character 1 = Section
Section defines the general type of procedure
- Section 0, Medical and Surgical, contains most
of the procedures reported in an inpatient setting
- Sections 1 through 9 comprise the Medical and
Surgical-related sections
- Sections B through D and F through H comprise
the Ancillary sections
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1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Med/Surg Section:
0 Medical and surgical
Med/Surg-related Sections:
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
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Ancillary Sections:
B Imaging
C Nuclear medicine
D Radiation oncology
F Physical rehabilitation and
diagnostic audiology
G Mental health
H Substance abuse treatment
8
1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Character 2 = Body System
Body System in the Medical and Surgical
Section defines
-
the general physiological system on which the
procedure is performed
or
-
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the anatomical region where the procedure is
performed
9
1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
0 Central Nervous system
1 Peripheral nervous system
2 Heart and great vessels
3 Upper arteries
4 Lower arteries
5 Upper veins
6 Lower veins
7 Lymphatic and hemic systems
8 Eye
9 Ear, nose, sinus
B Respiratory system
C Mouth and throat
D Gastrointestinal system
F Hepatobiliary system and
pancreas
G Endocrine system
H Skin and breast
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J Subcutaneous tissue and fascia
K Muscles
L Tendons
M Bursae and ligaments
N Head and facial bones
P Upper bones
Q Lower bones
R Upper joints
S Lower joints
T Urinary system
U Female reproductive system
V Male reproductive system
W Anatomical regions, general
X Anatomical regions, upper
extremities
Y Anatomical regions, lower
extremities
10
1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Character 3 = Root Operation
The root operation defines the precise and
distinctive objective of the procedure
If multiple procedures (as defined by distinct
objectives) are performed, then multiple
codes are assigned
There are 31 root operations in the medical and
surgical section
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1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
0 Alteration
1 Bypass
2 Change
3 Control
4 Creation
5 Destruction
6 Detachment
7 Dilation
8 Division
9 Drainage
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B Excision
C Extirpation
D Extraction
F Fragmentation
G Fusion
H Insertion
J Inspection
K Map
L Occlusion
M Reattachment
N Release
P Removal
Q Repair
R Replacement
S Reposition
T Resection
V Restriction
W Revision
U Supplement
X Transfer
Y Transplantation
12
1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
31 root operations can be arranged into 9 groups with similar
attributes:
… take out some or all of a body part (5)
… that take out solids, fluids, or gases from a body part (3)
… involving cutting or separation only (2)
… that put in or put back or move some or all of a body part (4)
… that alter the diameter or route of a tubular body part (4)
… that always involve a device (6)
… involving examination only (2)
… that include other repairs (2)
… that include other objectives (3)
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1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Root operations that take out some or all of a
body part:
Root operation
Objective of procedure
Site of procedure
Example
B Excision
Cutting out or off without
replacement
Some of a body part
Excision of a liver
mass
T Resection
Cutting out or off without
replacement
All of a body part
Total nephrectomy
6 Detachment
Cutting out or off
Extremity only, any
level
Below knee
amputation
5 Destruction
Eradicating
Some or all of a body
part
Fulguration of
bladder lesions
D Extraction
Pulling out or off
Some or all of a body
part
Tooth removal
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1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Root operations that take out solids, fluids, or gases
from a body part:
Root operation
Objective of procedure
9 Drainage
Taking or letting out fluids or Within a body part
gases
Incision and
drainage
C Extirpation
Taking or cutting out solid
matter
Within a body part
Thrombectomy
Endarterectomy
F Fragmentation
Breaking solid matter into
pieces
Within a body part
Lithotripsy
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Site of procedure
Example
15
1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Root operations involving cutting or separation only:
Root operation
Objective of procedure
Site of procedure
Example
8 Division
Cutting into or separating
a body part
Within a body part
Neurotomy
N Release
Freeing a body part from
constraint
Around a body part
Lysis of adhesions
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1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Root operations that put in or put back or move
some or all of a body part:
Root operation
Objective of procedure
Site of procedure
Example
Y Transplantation
Putting in a living body
part from a person or
animal
Some or all of a body
part
Liver transplant
M Reattachment
Putting back a detached
body part
Some or all of a body
part
Toe reattachment
X Transfer
Moving a body part to
function for a similar
body part
Some or all of a body
part
Flap graft
S Reposition
Moving a body part to
normal or other
suitable location
Some or all of a body
part
Reduction of a
displaced
fracture
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1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Root operations that alter the diameter or route of a
tubular body part:
Root operation
Objective of procedure
Site of procedure
Example
V Restriction
Partially closing orifice or
lumen
Tubular body part
Gastroesophageal
fundoplication
L Occlusion
Completely closing orifice
or lumen
Tubular body part
Fallopian tube ligation
7 Dilation
Expanding orifice or
lumen
Tubular body part
Percutaneous
transluminal
coronary angioplasty
1 Bypass
Altering route of passage
Tubular body part
Femoral-popliteal bypass
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1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Root operations that always involve a device:
Root operation
Objective of procedure
Site of procedure
Example
H Insertion
Putting in non-biological
device
In or on a body part
Central line insertion
R Replacement
Putting in device that replaces
a body part
Some or all of a
body part
Total hip
replacement
U Supplement
Putting in device that
reinforces or augments a
body part
In or on a body part
Hernia repair using
mesh
2 Change
Exchanging device without
cutting or puncturing
In or on a body part
Drainage tube
change
P Removal
Taking out device
In or on a body part
Central line removal
W Revision
Correcting a malfunctioning or
displaced device
In or on a body part
Revision of
pacemaker
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1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Root operations involving examination only:
Root operation
Objective of procedure
Site of procedure
Example
J Inspection
Visual or manual
exploration
Some or all of a
body part
Diagnostic cystoscopy
K Map
Location electrical
impulses or functional
areas
Brain or cardiac
conduction
mechanism
Cardiac
electrophysiology
study
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1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Root operations that include other repairs:
Root operation
Objective of procedure
Site of procedure
Example
3 Control
Stopping or attempting to
stop post-procedural
bleed
Anatomical region
Control of post-op
bleeding
Q Repair
Restoring body part to its
normal structure
Some or all of a body
part
Suture laceration
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1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Root operations that include other objectives:
Root operation
Objective of procedure
Site of procedure
Example
G Fusion
Rendering joint immobile
Joint
Spinal fusion
0 Alteration
Modifying body part for
cosmetic purposes
without affecting
function
Some or all of a body Face lift
part
4 Creation
Making new structure for
sex change operation
Perineum
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Artificial vagina or
penis
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ICD-10-PCS Index
Biopsy
See drainage, diagnostic
See excision, diagnostic
Amputation
See detachment
Cholecystectomy
See excision, gallbladder 0FB4
See resection, gallbladder 0FT4
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ICD-10-PCS Index
Nephrostomy
See bypass, urinary system 0T1
See drainage, urinary system 0T9
Laparoscopy
See inspection
Mediastinoscopy 0WJC4ZZ
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ICD-10-PCS Index
Debridement
Excisional, see excision
Non-excisional, see extraction
Hypogastric artery
use Artery, Internal Iliac, right
use Artery, Internal Iliac, left
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1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Character 4 = Body Part
Body part defines the specific anatomical site
where the procedure is performed
Up to 34 possible body part values in each body
system
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1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body
Part
Approach
Device
Qualifier
0 Section = Medical and Surgical
D Body System = Gastrointestinal System
B Root Operation = Excision: Cutting out or off, without replacement, a portion of a body part
Body Part
Approach
Device
Qualifier
1 Esophagus, Upper
2 Esophagus, Middle
3 Esophagus, Lower
4 Esophagogastric Junction
5 Esophagus
7 Stomach, Pylorus
8 Small Intestine
9 Duodenum
A Jejunum
B Ileum
C Ileocecal Valve
E Large Intestine
F Large Intestine, Right
G Large Intestine, Left
H Cecum
J Appendix
K Ascending Colon
L Transverse Colon
M Descending Colon
N Sigmoid Colon
P Rectum
0 Open
3 Percutaneous
4 Percutaneous Endoscopic
7 Via Natural or Artificial
Opening
8 Via Natural or Artificial
Opening Endoscopic
Z No Device
X Diagnostic
Z No Qualifier
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Body Part Key
Anatomical term:
PCS description:
Anterior cerebral artery
Intracranial artery
Gastric lymph node
Lymphatic system, aorta
Lateral collateral ligament
Knee bursa and ligament, right
Knee bursa and ligament, left
Left inferior phrenic vein
Renal vein, left
Lunotriquetral ligament
Hand bursa and ligament, right
Hand bursa and ligament, left
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Body Part Key
Anatomical term:
PCS description:
Medial rectus muscle
Extra ocular muscle, right
Extra ocular muscle, left
Rectus abdominus muscle
Abdomen muscle, right
Abdomen muscle, left
Post auricular lymph node
Lymphatic, right neck
Lymphatic, left neck
Left gastroepiploic artery
Splenic artery
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1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Character 5 = Approach
Approach defines the technique used to reach
the site of the procedure
7 different approach values
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1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Approaches through the skin or mucous membrane
- 0 Open
- 3 Percutaneous
- 4 Percutaneous endoscopic
Approaches through an orifice
- 7 Via natural or artificial opening
- 8 Via natural or artificial opening endoscopic
- F Via natural or artificial opening with percutaneous
endoscopic assistance
External
- X Procedures performed directly on the skin or mucous
membrane and procedures performed indirectly by the
application of external force through the skin or mucous
membrane
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1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
0 Section = Medical and Surgical
U Body System = Female Reproductive System
T Root Operation = Resection: Cutting out or off, without replacement, all of a body part
Body Part
Approach
Device
Qualifier
0 Ovary, right
1 Ovary, left
2 Ovaries, bilateral
5 Fallopian tube, right
6 Fallopian tube, left
7 Fallopian tubes, bilateral
9 Uterus
0 Open
4 Percutaneous Endoscopic
7 Via Natural or Artificial Opening
8 Via Natural or Artificial Opening Endoscopic
F Via natural or artificial opening endoscopic
with percutaneous endoscopic assistance
Z No Device
Z No Qualifier
4 Uterine supporting structure
C Cervix
F Cul-de-sac
G Vagina
0 Open
4 Percutaneous Endoscopic
7 Via Natural or Artificial Opening
8 Via Natural or Artificial Opening Endoscopic
Z No Device
Z No Qualifier
J Clitoris
L Vestibular gland
M Vulva
0 Open
X External
Z No Device
Z No Qualifier
K Hymen
0 Open
4 Percutaneous Endoscopic
7 Via Natural or Artificial Opening
8 Via Natural or Artificial Opening Endoscopic
X External
Z No Device
Z No Qualifier
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1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Character 6 = Device
Includes only devices that remain after the procedure is
completed
Not included:
- Instruments for visualization are specified in the approach
character
- Materials incidental to a procedure such as clips and sutures
are not considered devices
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1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Included:
- Biological or synthetic material that takes the place of all or a
portion of a body part (e.g., skin graft, joint prosthesis)
- Biological or synthetic material that assists or prevents a
physiological function (e.g., urinary catheter, IUD)
- Therapeutic material that is not absorbed by, eliminated by,
or incorporated into a body part (e.g., radioactive implant,
orthopedic pins). Therapeutic materials that are considered
devices can be removed.
- Mechanical or electronic appliances used to assist, monitor,
take the place of, or prevent a physiological function (e.g.,
pacemaker)
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Device Key (example)
COGNIS® CRT-D
Use: Cardiac Resynchronization Defibrillator
Pulse Generator for Insertion in
Subcutaneous Tissue and Fascia
Colonic Z-Stent®
Use: Intraluminal Device
Continuous Glucose Monitoring
(CGM) device
Use: Monitoring Device
Cormet Hip Resurfacing System
Use: Resurfacing Device in Lower Joints
CoRoent® XL
Use: Interbody Fusion Device in Lower Joints
Corox OTW (Bipolar) Lead
Use: Cardiac Lead, Pacemaker for Insertion in
Heart and Great Vessels
Cortical strip neurostimulator lead
Use: Neurostimulator Lead in Central Nervous
System
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Device Aggregation Table (examples)
Specific Device
for
Operation
in Body System
General
Device
Autologous Arterial
Tissue
All
applicable
Heart and Great Vessels
Lower Arteries Lower
Veins Upper Arteries
Upper Veins
7 Autologous
Tissue
Substitute
Cardiac Lead,
Defibrillator
Insertion
Heart and Great Vessels
M Cardiac
Lead
Cardiac
Resynchronization
Defibrillator Pulse
Generator
Insertion
Subcutaneous Tissue and P Cardiac
Fascia
Rhythm
Related
Device
External Fixation Device,
Hybrid
Insertion
Lower Bones Upper
Bones
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5 External
Fixation
Device
36
1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
0 Section = Medical and Surgical
0 Body System = Central Nervous System
1 Root Operation = Bypass: Altering the route of passage of the contents of a tubular body part
Body Part
Approach
Device
Qualifier
6 Cerebral ventricle
0 Open
3 Percutaneous
7 Autologous tissue substitute
J Synthetic substitute
K Non-autologous tissue
substitute
0 Nasopharynx
1 Mastoid sinus
2 Atrium
3 Blood vessel
4 Pleural cavity
5 Intestine
6 Peritoneal cavity
7 Urinary tract
8 Bone marrow
B Cerebral cisterns
U Spinal canal
0 Open
3 Percutaneous
7 Autologous tissue substitute
J Synthetic substitute
K Non-autologous tissue
substitute
4 Pleural cavity
6 Peritoneal cavity
7 Urinary tract
9 Fallopian tube
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1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
Character 7 = Qualifier
Qualifier defines an additional attribute of the
procedure performed, if applicable
May have a narrow application, to a specific
root operation, body system, or body part
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1
2
3
4
5
6
7
Section
Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
0 Section = Medical and Surgical
4 Body System = Lower Arteries
1 Root Operation = Bypass: Altering the route of passage of the contents of a tubular body part
Body Part
Approach
Device
Qualifier
K Femoral artery, right
L Femoral artery, left
0 Open
4 Percutaneous endoscopic
9 Autologous venous tissue
A Autologous arterial tissue
J Synthetic substitute
K Non-autologous tissue
substitute
Z no device
H Femoral artery, right
J Femoral artery, left
K Femoral arteries, bilateral
L Popliteal artery
M Peroneal artery
N Posterior tibial artery
P Foot artery
Q Lower extremity artery
S Lower extremity vein
M Popliteal artery, right
N Popliteal artery, left
0 Open
4 Percutaneous endoscopic
9 Autologous venous tissue
A Autologous arterial tissue
J Synthetic substitute
K Non-autologous tissue
substitute
Z no device
L Popliteal artery
M Peroneal artery
P Foot artery
Q Lower extremity artery
S Lower extremity vein
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ICD-10-PCS Coding Guidelines
Table of Contents
A. Conventions
1
B. Medical and Surgical Section Guidelines
4
-
2. Body System
3. Root Operation
4. Body Part
5. Approach
6. Device
C. Obstetrics Section Guidelines
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4
5
9
12
13
14
40
ICD-10-PCS Coding Guidelines
A. Conventions
A6
The purpose of the alphabetic index is to locate the
appropriate table that contains all information
necessary to construct a procedure code.
The PCS Tables should always be consulted to find
the most appropriate valid code.
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ICD-10-PCS Coding Guidelines
A. Conventions
A7
It is not required to consult the index first before
proceeding to the tables to complete the code. A
valid code may be chosen directly from the
tables.
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ICD-10-PCS Coding Guidelines
A. Conventions
A8
All seven characters must be specified to be a valid
code. If the documentation is incomplete for
coding purposes, the physician should be queried
for the necessary information
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ICD-10-PCS Coding Guidelines
A. Conventions
A9
Within a PCS table, valid codes include all
combinations of choices in characters 4 through 7
contained in the same row of the table.
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ICD-10-PCS Coding Guidelines
A. Conventions
A10
“And,” when used in a code description, means
“and/or.”
Example: Lower Arm and Wrist Muscle means
lower arm and/or wrist muscle.
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2012 ICD-10-PCS Coding Guidelines
A. Conventions
A11
Many of the terms used to construct PCS codes are
defined within the system.
- It is the coder’s responsibility to determine what
the documentation in the medical record
equates to in the PCS definitions.
- The physician is not expected to use the terms used
in PCS code descriptions,
- nor is the coder required to query the physician
when the correlation between the documentation
and the defined PCS terms is clear.
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ICD-10-PCS Coding Guidelines
Medical and Surgical Section Guidelines (section 0)
B2. Body System
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.
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ICD-10-PCS Coding Guidelines
B3. Root Operation
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.
Example: Diagnostic excision of liver and pancreas are
coded separately.
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ICD-10-PCS Coding Guidelines
B3. Root Operation
Multiple procedures
B3.2
b. The same root operation is repeated at different body sites
that are included in the same body part value.
Example: 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.
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ICD-10-PCS Coding Guidelines
B3. Root Operation
Multiple procedures
B3.2
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.
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ICD-10-PCS Coding Guidelines
B3. Root Operation
Multiple procedures
B3.2
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
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ICD-10-PCS Coding Guidelines
B3. Root Operation
Overlapping body layers
B3.5
If the root operations Excision, 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.
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ICD-10-PCS Coding Guidelines
B3. Root Operation
Discontinued procedures
B3.3
If the intended procedure is discontinued, 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.
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ICD-10-PCS Coding Guidelines
B4. Body Part
General guidelines
B4.1b
If the prefix “peri” is combined with a body part to
identify the site of the procedure, the procedure is
coded to the body part named.
Example: A procedure site identified as perirenal is
coded to the kidney body part.
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ICD-10-PCS Coding Guidelines
B5. Approach
Open approach with percutaneous endoscopic
assistance
B5.2
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.
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ICD-10-PCS Coding Guidelines
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.
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Coding Clinic transition timeline
First Quarter 2014:
- Last issue of Coding Clinic for ICD-9-CM was
published
- First issue of Coding Clinic for ICD-10-CM and
ICD-10-PCS was published
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Exercises
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Exercise 1
Percutaneous needle biopsy liver, left lobe
Biopsy
see Drainage with qualifier Diagnostic
see Excision with qualifier Diagnostic
Bone Marrow see Extraction with qualifier
diagnostic
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Exercise 1
Percutaneous needle biopsy liver, left lobe
Excision
Liver 0FB0
Left lobe 0FB2
Right lobe OFB1
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Exercise 1
0FB23ZX Perc needle biopsy of the liver, left lobe
Section
0
Body system
F Hepatobiliary and Pancreas
Root operation
B Excision
Body part
2
Liver, left lobe
Approach
3
Percutaneous
Device
Z No device
Qualifier
X Diagnostic
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Medical and surgical
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Exercise 2
ERCP with balloon dilation of common bile duct
Dilation
Duct
Common bile 0F798ZZ
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Exercise 2
0F798ZZ ERCP with balloon dilation of common bile duct
Section
Body system
Root operation
Body part
Approach
Device
Qualifier
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0
F
7
9
8
Medical and surgical
Hepatobiliary and Pancreas
Dilation
Common bile duct
Via natural or artificial opening
endoscopic
Z No device
Z No qualifier
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Exercise 3
ventriculoperitoneal shunt (open) synthetic shunt
Shunt creation see Bypass
Bypass
Cerebral Ventricle 0016
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Exercise 3
00160J6 a v-p shunt (open) synthetic shunt
Section
Body system
Root operation
Body part
Approach
Device
Qualifier
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0
0
1
6
0
J
6
Medical and surgical
Central nervous system
Bypass
Cerebral ventricle
Open
Synthetic substitute
Peritoneal cavity
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Exercise 4
right common carotid endarterectomy (open)
Endarterectomy
see Extirpation, lower arteries 04C
see Extirpation, upper arteries 03C
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Exercise 4
right common carotid endarterectomy (open)
Extirpation
Artery
Common carotid
Left
03CJ
Right 03CH
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Exercise 4
03CH0ZZ right common carotid endarterectomy (open)
Section
Body system
Root operation
Body part
Approach
Device
Qualifier
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0
3
C
H
0
Z
Z
Medical and surgical
Upper Arteries
Extirpation
Common Carotid Artery, Right
Open
No Device
No Qualifier
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Exercise 5
Mechanical ventilation for 6 days
Mechanical ventilation see Performance,
Respiratory 5A19
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Exercise 5
Mechanical ventilation for 6 days
Performance
Respiratory
24-96 Consecutive Hours, Ventilation 5A1945Z
Greater than 96 Consecutive Hours, Ventilation
5A1955Z
Less than 24 Consecutive Hours, Ventilation
5A1935Z
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Exercise 5
5A1955Z mechanical ventilation for 6 days
Section
5
Body system
Root operation
Body System
Duration
Function
Qualifier
A
1
9
5
5
Z
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Extracorporeal Assistance
and Performance
Physiological Systems
Performance
Respiratory
Greater than 96 Consec Hrs
Ventilation
No Qualifier
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Questions?
Barry Libman, MS, RHIA, CDIP, CCS, CCS-P
President, Barry Libman Inc.
President, Libman Education
978-369-7180
AHIMA-approved ICD-10 Trainer
AHIMA ICD-10 Ambassador
[email protected]
www.barrylibmaninc.com
www.LibmanEducation.com
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