2022 ICD-10-PCS Official Guidelines for Coding and Reporting
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ICD-10-PCS Official Guidelines for Coding
and Reporting
2022
The Centers for Medicare and Medicaid Services (CMS) and the National Center for
Health Statistics (NCHS), two departments within the U.S. Federal Government’s
Department of Health and Human Services (DHHS) provide the following guidelines for
coding and reporting using the International Classification of Diseases, 10th Revision,
Procedure Coding System (ICD-10-PCS). These guidelines should be used as a
companion document to the official version of the ICD-10-PCS as published on the CMS
website. The ICD-10-PCS is a procedure classification published by the United States for
classifying procedures performed in hospital inpatient health care settings.
These guidelines have been approved by the four organizations that make up the
Cooperating Parties for the ICD-10-PCS: the American Hospital Association (AHA), the
American Health Information Management Association (AHIMA), CMS, and NCHS.
These guidelines are a set of rules that have been developed to accompany and
complement the official conventions and instructions provided within the ICD-10-PCS
itself. They are intended to provide direction that is applicable in most
circumstances. However, there may be unique circumstances where exceptions are
applied. The instructions and conventions of the classification take precedence over
guidelines. These guidelines are based on the coding and sequencing instructions in the
Tables, Index and Definitions of ICD-10-PCS, but provide additional instruction.
Adherence to these guidelines when assigning ICD-10-PCS procedure codes is required
under the Health Insurance Portability and Accountability Act (HIPAA). The procedure
codes have been adopted under HIPAA for hospital inpatient healthcare settings. A joint
effort between the healthcare provider and the coder is essential to achieve complete and
accurate documentation, code assignment, and reporting of diagnoses and procedures.
These guidelines have been developed to assist both the healthcare provider and the coder
in identifying those procedures that are to be reported. The importance of consistent,
complete documentation in the medical record cannot be overemphasized. Without such
documentation accurate coding cannot be achieved.
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Table of Contents
A. Conventions .……………………………………………………… XXXXXXXXXX
B. Medical and Surgical Section Guidelines ....………………………....5
2. Body System ……………………………………………… XXXXXXXXXX
3. Root Operation………….……………………………………...5
4. Body Part ……………………………………………………...11
5. Approach ………………………………………………….…..14
6. Device ……………………………………………………….....15
C. Obstetrics Section Guidelines………………………………………..16
D. Radiation Therapy Guidelines………………………………………16
E. New Technology Section Guidelines………………………………...17
F. Selection of Principal Procedure…………………………………….18
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Conventions
A1
ICD-10-PCS codes are composed of seven characters. Each character is an axis of
classification that specifies information about the procedure performed. Within a defined
code range, a character specifies the same type of information in that axis of
classification.
Example: The fifth axis of classification specifies the approach in sections 0 through 4
and 7 through 9 of the system.
A2
One of 34 possible values can be assigned to each axis of classification in the seven-
character code: they are the numbers 0 through 9 and the alphabet (except I and O
ecause they are easily confused with the numbers 1 and 0). The number of unique values
used in an axis of classification differs as needed.
Example: Where the fifth axis of classification specifies the approach, seven different
approach values are cu
ently used to specify the approach.
A3
The valid values for an axis of classification can be added to as needed.
Example: If a significantly distinct type of device is used in a new procedure, a new
device value can be added to the system.
A4
As with words in their context, the meaning of any single value is a combination of its
axis of classification and any preceding values on which it may be dependent.
Example: The meaning of a body part value in the Medical and Surgical section is always
dependent on the body system value. The body part value 0 in the Central Nervous body
system specifies Brain and the body part value 0 in the Peripheral Nervous body system
specifies Cervical Plexus.
A5
As the system is expanded to become increasingly detailed, over time more values will
depend on preceding values for their meaning.
Example: In the Lower Joints body system, the device value 3 in the root operation
Insertion specifies Infusion Device and the device value 3 in the root operation
Replacement specifies Ceramic Synthetic Substitute.
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.
A7
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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.
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.
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. In the example below, 0JHT3VZ is a
valid code, and 0JHW3VZ is not a valid code.
Section: 0 Medical and Surgical
Body System: J Subcutaneous Tissue and Fascia
Operation: H Insertion: 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
Body Part Approach Device Qualifier
S Subcutaneous Tissue and
Fascia, Head and Neck
V Subcutaneous Tissue and
Fascia, Upper Extremity
W Subcutaneous Tissue and
Fascia, Lower Extremity
0 Open
3 Percutaneous
1 Radioactive Element
3 Infusion Device
Y Other Device
Z No
Qualifier
T Subcutaneous Tissue and
Fascia, Trunk
0 Open
3 Percutaneous
1 Radioactive Element
3 Infusion Device
V Infusion Pump
Y Other Device
Z No
Qualifier
A10
“And,” when used in a code description, means “and/or,” except when used to describe a
combination of multiple body parts for which separate values exist for each body part
(e.g., Skin and Subcutaneous Tissue used as a qualifier, where there are separate body
part values for “Skin” and “Subcutaneous Tissue”).
Example: Lower Arm and Wrist Muscle means lower arm and/or wrist muscle.
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 co
elation
etween the documentation and the defined PCS terms is clear.
Example: When the physician documents “partial resection” the coder can independently
co
elate “partial resection” to the root operation Excision without querying the physician
for clarification.
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Medical and Surgical Section Guidelines (section 0)
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
ody 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
espectively.
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
each the operative site and close the operative site, including anastomosis of a tubular
ody part, are also not coded separately.
Examples: Resection of a joint as part of a joint replacement procedure is included in the
oot 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. 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.
. 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
oth 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
egion 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
ecomes 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 ma
ow 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.
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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
east followed by partial mastectomy at the same procedure site,
oth 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 de
idement that includes skin and subcutaneous tissue and muscle
is coded