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.
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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.
Integral Components
Procedure components defined as integral to a root operation are not coded separately.
Procedural Steps
Steps to reach and close the operative site, including anastomosis, are 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.
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Multiple Procedures
B3.2 During the same operative episode, multiple procedures are coded if:
a. Different Body Parts
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. Multiple Separate Parts
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. Distinct Objectives
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. Approach Conversion
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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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.
Clinical Scenario ExampleA 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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Biopsy Procedures
B3.4a Biopsy Coding
Biopsy procedures are coded using the root operations Excision, Extraction, or Drainage and the qualifier Diagnostic.
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.
B3.4b Biopsy Followed by Treatment
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.
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Overlapping Body Layers & Bypass Procedures
B3.5 Overlapping body layers
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.
B3.6a Bypass procedures
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
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 Multiple coronary arteries
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.
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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 1: Control
Silver nitrate cautery to treat acute nasal bleeding is coded to the root operation Control.
Example 2: Occlusion
Liquid embolization of the right internal iliac artery to treat acute hematoma by stopping blood flow is coded to the root operation Occlusion.
Example 3: Integral Procedure
Suctioning of residual blood to achieve hemostasis during a transbronchial cryobiopsy is considered integral to the cryobiopsy procedure and is not coded separately.
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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.
Key DistinctionExample: Left upper lung lobectomy is coded to Resection of Upper Lung Lobe, Left rather than Excision of Lung, Left.
B3.9 Excision for graft
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.
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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.
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 Device Combinations
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.
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Inspection & Occlusion Procedures
B3.11a Inspection procedures
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 Multiple body parts inspected
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 Different approaches
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.
B3.12 Occlusion vs. Restriction for vessel embolization
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.
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Release, Division & Reposition Procedures
B3.13 Release procedures
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.
B3.14 Release vs. Division
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.
B3.15 Reposition for fracture treatment
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.
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Transplantation, Transfer & Replacement Procedures
B3.16 Transplantation vs. Administration
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.
B3.17 Transfer procedures using multiple tissue layers
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.
B3.18 Excision/Resection followed by replacement
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 where both are coded:
- 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 where excision/resection is NOT coded separately:
- 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.
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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.
Detachment Qualifier Definitions
*When coding amputation of Hand and Foot: 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.
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B4-B6: Body Part, Approach & Device Guidelines
B4. Body Part
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.
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.
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.
B5. Approach
B5.2a Procedures performed using the open approach with percutaneous endoscopic assistance are coded to the approach Open.
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, are coded to the approach value Percutaneous Endoscopic.
B5.3a Procedures performed within an orifice on structures that are visible without the aid of any instrumentation are coded to the approach External.
B6. Device
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.
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.
B6.2 A separate procedure to put in a drainage device is coded to the root operation Drainage with the device value Drainage Device.
Additional Key GuidelinesB4.4 Coronary arteries: The coronary arteries are classified as a single body part that is further specified by the number of arteries treated.B4.5 Tendons, ligaments, bursae and fascia near a joint: 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.B4.8 Upper and lower intestinal tract: 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 from the jejunum down to and including the rectum and anus.
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