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ICD 10 PCS
| Question | Answer |
|---|---|
| Suzy Buys Root Beer At Dairy Queen stands for? | Section, Body system, Root operation, Body part, Approach, Device, Qualifier Structure of codes in the medical/surgical sections of ICD 10 PCS |
| Approach | the way the procedure site is reached (for example: open or percutaneous) Suzy Buys Root Beer At Dairy Queen |
| Qualifier | it carries additional information for that particular procedure Suzy Buys Root Beer At Dairy Queen |
| Root operation | the objective of the procedure; in this section alone there are 31 possible objectives Suzy Buys Root Beer At Dairy Queen |
| Alteration Definition | Modifying the anatomic structure of a body part without affecting the function of the body part |
| Alteration Explanation | Principal purpose is to improve appearance |
| Alteration Includes/Examples | Face lift, breast augmentation |
| Bypass Definition | Altering the route of passage of the contents of a tubular body part |
| Bypass Explanation | Rerouting contents of a body part to a downstream area of the normal route, to a similar route and body part, or to an abnormal route and dissimilar body part. Includes one or more anastomoses, with or without the use of a device |
| Bypass Includes/Examples | Coronary artery bypass, colostomy formation |
| Change Definition | Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane |
| Change Explanation | All CHANGE procedures are coded using the approach EXTERNAL |
| Change Includes/Examples | Urinary catheter change, gastrostomy tube change |
| Control Definition | Stopping, or attempting to stop, postprocedural bleeding |
| Control Explanation | The site of the bleeding is coded as an anatomical region and not to a specific body part |
| Control Includes/Examples | Control of post-prostatectomy hemorrhage, control of post-tonsillectomy hemorrhage |
| Creation Definition | Making a new genital structure that does not take over the function of a body part |
| Creation Explanation | Used only for sex change operations |
| Creation Includes/Examples | Creation of vagina in a male, creation of penis in a female |
| Destruction Definition | Physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent |
| Destruction Explanation | None of the body part is physically taken out |
| Destruction Includes/Examples | Fulguration of rectal polyp, cautery of skin lesion |
| Detachment Definition | Cutting off all or a portion of the upper or lower extremities |
| Detachment Explanation | The body part value is the site of the detachment, with a qualifier if applicable to further specify the level where the extremity was detached |
| Detachment Includes/Examples | Below knee amputation, disarticulation of shoulder |
| Dilation Definition | Expanding an orifice or the lumen of a tubular body part |
| Dilation Explanation | The orifice can be a natural orifice or an artificially created orifice. Accomplished by stretching a tubular body part using intraluminal pressure or by cutting part of the orifice or wall of the tubular body part |
| Dilation Includes/Examples | Percutaneous transluminal angioplasty, pyloromyotomy |
| Division Definition | Cutting into a body part, without draining fluids and/or gases from the body part, in order to separate or transect a body part |
| Division Explanation | All or a portion of the body part is separated into two or more portions |
| Division Includes/Examples | Spinal cordotomy, osteotomy |
| Drainage Definition | Taking or letting out fluids and/or gases from a body part |
| Drainage Explanation | The qualifier DIAGNOSTIC is used to identify drainage procedures that are biopsies |
| Drainage Includes/Examples | Thoracentesis, incision and drainage |
| Excision Definition | Cutting out or off, without replacement, a portion of a body part |
| Excision Explanation | The qualifier DIAGNOSTIC is used to identify excision procedures that are biopsies |
| Excision Includes/Examples | Partial nephrectomy, liver biopsy |
| Extirpation Definition | Taking or cutting out solid matter from a body part |
| Extirpation Explanation | The solid matter may be an abnormal byproduct of a biological function or a foreign body; it may be imbedded in a body part or in the lumen of a tubular body part. The solid matter may or may not have been previously broken into pieces |
| Extirpation Includes/Examples | Thrombectomy, choledocholithotomy |
| Extraction Definition | Pulling or stripping out or off all or a portion of a body part by the use of force |
| Extraction Explanation | The qualifier DIAGNOSTIC is used to identify extraction procedures that are biopsies |
| Extraction Includes/Examples | Dilation and curettage, vein stripping |
| Fragmentation Definition | Breaking solid matter in a body part into pieces |
| Fragmentation Explanation | Physical force (e.g., manual, ultrasonic) applied directly or indirectly is used to break the 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 |
| Fragmentation Includes/Examples | Extracorporeal shockwave lithotripsy, transurethral lithotripsy |
| Fusion Definition | Joining together portions of an articular body part rendering the articular body part immobile |
| Fusion Explanation | The body part is joined together by fixation device, bone graft, or other means |
| Fusion Includes/Examples | Spinal fusion, ankle arthrodesis |
| Insertion Definition | Putting in a nonbiological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part |
| Insertion Includes/Examples | Insertion of radioactive implant, insertion of central venous catheter |
| Inspection Definition | Visually and/or manually exploring a body part |
| Inspection Explanation | Visual exploration may be performed with or without optical instrumentation. Manual exploration may be performed directly or through intervening body layers |
| Inspection Includes/Examples | Diagnostic arthroscopy, exploratory laparotomy |
| Map Definition | Locating the route of passage of electrical impulses and/or locating functional areas in a body part |
| Map Explanation | Applicable only to the cardiac conduction mechanism and the central nervous system |
| Map Includes/Examples | Cardiac mapping, cortical mapping |
| Occlusion Definition | Completely closing an orifice or the lumen of a tubular body part |
| Occlusion Explanation | The orifice can be a natural orifice or an artificially created orifice |
| Occlusion Includes/Examples | Fallopian tube ligation, ligation of inferior vena cava |
| Reattachment Definition | Putting back in or on all or a portion of a separated body part to its normal location or other suitable location |
| Reattachment Explanation | Vascular circulation and nervous pathways may or may not be reestablished |
| Reattachment Includes/Examples | Reattachment of hand, reattachment of avulsed kidney |
| Release Definition | Freeing a body part from an abnormal physical constraint |
| Release Explanation | Some of the restraining tissue may be taken out but none of the body part is taken out |
| Release Includes/Examples | Adhesiolysis, carpal tunnel release |
| Removal Definition | Taking out or off a device from a body part |
| Removal Explanation | 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 the root operation CHANGE. Otherwise, the procedure for taking out a device is coded to the root operation REMOVAL |
| Removal Includes/Examples | Drainage tube removal, cardiac pacemaker removal |
| Repair Definition | Restoring, to the extent possible, a body part to its normal anatomic structure and function |
| Repair Explanation | Used only when the method to accomplish the repair is not one of the other root operations |
| Repair Includes/Examples | Colostomy takedown, suture of laceration |
| Replacement Definition | Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part |
| Replacement Explanation | The body part may have been taken out or replaced, or may be 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 |
| Replacement Includes/Examples | Total hip replacement, bone graft, free skin graft |
| Reposition Definition | Moving to its normal location, or other suitable location, all or a portion of a body part |
| Reposition Explanation | The body part is moved to a new location from an abnormal location, or from a normal 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 Includes/Examples | Reposition of undescended testicle, fracture reduction |
| Resection Definition | Cutting out or off, without replacement, all of a body part |
| Resection Includes/Examples | Total nephrectomy, total lobectomy of lung |
| Restriction Definition | Partially closing an orifice or the lumen of a tubular body part |
| Restriction Explanation | The orifice can be a natural orifice or an artificially created orifice |
| Restriction Includes/Examples | Esophagogastric fundoplication, cervical cerclage |
| Revision Definition | Correcting, to the extent possible, a portion of a malfunctioning device or the position of a displaced device |
| Revision Explanation | Revision can include correcting a malfunctioning or displaced device by taking out and/or putting in part of the device |
| Revision Includes/Examples | Adjustment of position of pacemaker lead, recementing of hip prosthesis |
| Supplement Definition | Putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part |
| Supplement Explanation | 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 |
| Includes/Examples | Herniorrhaphy using mesh, free nerve graft, mitral valve ring annuloplasty, put a new acetabular liner in a previous hip replacement |
| Transfer Definition | 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 |
| Transfer Explanation | The body part transferred remains connected to its vascular and nervous supply |
| Transfer Includes/Examples | Tendon transfer, skin pedicle flap transfer |
| Transplantation Definition | 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 |
| Transplantation Explanation | 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 |
| Transplantation Includes/Examples | Kidney transplant, heart transplant |
| External Definition | 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 |
| Open Definition | Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure |
| Percutaneous Definition | Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure |
| Percutaneous Endoscopic Definition | Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure |
| Via Natural or Artificial Opening Definition | Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure |
| Via Natural or Artificial Opening Endoscopic Definition | Entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure |
| Via Natural or Artificial Opening With Percutaneous Endoscopic Assistance Definition | Entry of instrumentation through a natural or artificial external opening and entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to aid in the performance of the procedure |
| 1st Toe, Left 1st Toe, Right | Hallux |
| Abdomen Muscle, Left Abdomen Muscle, Right | External oblique muscle, Internal oblique muscle, Pyramidalis muscle, Rectus abdominis muscle, Transversus abdominis muscle |
| Abdominal Aorta | Inferior phrenic artery, Lumbar artery, Median sacral artery, Middle suprarenal artery, Ovarian artery, Testicular artery |
| Abdominal Sympathetic Nerve | Abdominal aortic plexus, Auerbach's (myenteric) plexus, Celiac (solar) plexus, Celiac ganglion, Gastric plexus, Hepatic plexus, Inferior hypogastric plexus, Inferior mesenteric ganglion, Inferior mesenteric plexus, Meissner's (submucous) plexus |
| Abdominal Sympathetic Nerve | Myenteric (Auerbach's) plexus, Pancreatic plexus, Pelvic splanchnic nerve, Renal plexus, Solar (celiac) plexus, Splenic plexus, Submucous (Meissner's) plexus, Superior hypogastric plexus, Superior mesenteric ganglion, Superior mesenteric plexus |
| Abdominal Sympathetic Nerve | Suprarenal plexus |
| Abducens Nerve | Sixth cranial nerve |
| Accessory Nerve | Eleventh cranial nerve |
| Acoustic Nerve | Cochlear nerve, Eighth cranial nerve, Scarpa's (vestibular) ganglion, Spiral ganglion, Vestibular (Scarpa's) ganglion, Vestibular nerve, Vestibulocochlear nerve |
| Adenoids | Pharyngeal tonsil |
| Adrenal Gland (Left, Right or Bilateral) | Suprarenal gland |
| Ampulla of Vater | Duodenal ampulla, Hepatopancreatic ampulla |
| Anal Sphincter | External anal sphincter, Internal anal sphincter |
| Ankle Bursa and Ligament (Left & Right) | Calcaneofibular ligament, Deltoid ligament, Ligament of the lateral malleolus, Talofibular ligament |
| Ankle Joint (Left & Right) | Inferior tibiofibular joint, Talocrural joint |
| Anterior Chamber (Left & Right) | Aqueous humour |
| Anterior Tibial Artery (Left & Right) | Anterior lateral malleolar artery, Anterior medial malleolar artery, Anterior tibial recurrent artery, Dorsalis pedis artery, Posterior tibial recurrent artery |
| Anus | Anal orifice |
| Aortic Valve | Aortic annulus |
| Appendix | Vermiform appendix |
| Ascending Colon | Hepatic flexure |
| Atrial Septum | Interatrial septum |
| Atrium, Left | Atrium pulmonale, Left auricular appendix |
| Atrium, Right | Atrium dextrum cordis, Right auricular appendix, Sinus venosus |
| Auditory Ossicle (Left & Right) | Incus, Malleus, Ossicular chain, Stapes |
| Axillary Artery (Left & Right) | Anterior circumflex humeral artery, Lateral thoracic artery, Posterior circumflex humeral artery, Subscapular artery, Superior thoracic artery, Thoracoacromial artery |
| Azygos Vein | Right ascending lumbar vein, Right subcostal vein |
| Basal Ganglia | Basal nuclei, Claustrum, Corpus striatum, Globus pallidus, Substantia nigra, Subthalamic nucleus |
| Basilic Vein (Left & Right) | Median antebrachial vein, Median cubital vein |
| Bladder | Trigone of bladder |
| Brachial Artery (Left & Right) | Inferior ulnar collateral artery, Profunda brachii, Superior ulnar collateral artery |
| Brachial Plexus | Axillary nerve, Dorsal scapular nerve, First intercostal nerve, Long thoracic nerve, Musculocutaneous nerve, Subclavius nerve, Suprascapular nerve |
| Brachial Vein (Left & Right) | Radial vein, Ulnar vein |
| Brain | Cerebrum, Corpus callosum, Encephalon |
| Breast (Left, Right & Bilateral) | Mammary duct, Mammary gland |
| Buccal Mucosa | Buccal gland, Labial gland, Molar gland, Palatine gland |
| Carotid Bodies (Left, Right & Bilateral) | Carotid glomus |
| Carpal Joint (Left & Right) | Intercarpal joint, Midcarpal joint, Capitate bone, Hamate bone, Lunate bone, Pisiform bone, Scaphoid bone, Trapezium bone, Trapezoid bone, Triquetral bone |
| Celiac Artery | Celiac trunk |
| Cephalic Vein (Left & Right) | Accessory cephalic vein |
| Cerebellum | Culmen |
| Cerebral Hemisphere | Frontal lobe, Occipital lobe, Parietal lobe, Temporal lobe |
| Cerebral Meninges | Arachnoid mater, Leptomeninges, Pia mater |
| Cerebral Ventricle | Aqueduct of Sylvius, Cerebral aqueduct (Sylvius), Choroid plexus, Ependyma, Foramen of Monro (intraventricular), Fourth ventricle, Interventricular foramen (Monro), Left lateral ventricle, Right lateral ventricle, Third ventricle |
| Cervical Nerve | Greater occipital nerve, Suboccipital nerve, Third occipital nerve |
| Cervical Plexus | Ansa cervicalis, Cutaneous (transverse) cervical nerve, Great auricular nerve, Lesser occipital nerve, Supraclavicular nerve, Transverse (cutaneous) cervical nerve |
| Cervical Vertebra | Spinous process, Vertebral arch, Vertebral foramen, Vertebral lamina, Vertebral pedicle |
| Cervical Vertebral Joint | Atlantoaxial joint, Cervical facet joint |
| Cervical Vertebral Joints, 2 or more | Cervical facet joint |
| Cervicothoracic Vertebral Joint | Cervicothoracic facet joint |
| Cisterna Chyli | Intestinal lymphatic trunk, Lumbar lymphatic trunk |
| Coccygeal Glomus | Coccygeal body |
| Colic Vein | Ileocolic vein, Left colic vein, Middle colic vein, Right colic vein |
| Conduction Mechanism | Atrioventricular node, Bundle of His, Bundle of Kent, Sinoatrial node |
| Conjunctiva (Left & Right) | Plica semilunaris |
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