Determining the ICD-10-PCS Code
Coding Example 2
Procedure: Resection of appendix, percutaneous endoscopic approach
Click the Index tab to find the first 3 values of the code. Then, click the Table 0DT tab to see the value choices for characters 4-7 of the code. Click the Character Section Table tab to see the value for each character of the code. Last, click the Explanation tab for a full description of each character in the code.
Step 1: Locate the main term entry Appendectomy in the Index for the type of procedure. The subterms Resection, Appendix direct the user to Table 0DT to complete the code.
Appendectomysee Excision, Appendix 0DBJ
see Resection, Appendix 0DTJ
Step 2: Locate Table 0DT, which shows the possible value choices for the last 4 characters of the code. You need all 7 characters to complete the code.
| Body Part | Approach | Device | Qualifier |
|---|---|---|---|
| 1 Esophagus, Upper 2 Esophagus, Middle 3 Esophagus, Lower 4 Esophagogastric Junction 5 Esophagus 6 Stomach 7 Stomach, Pylorus 8 Small Intestine 9 Duodenum A Jejunum B Ileum C Ileocecal Valve E Large Intestine H Cecum K Ascending Colon P Rectum Q Anus | 0 Open 4 Percutaneous Endoscopic 7 Via Natural or Artificial Opening 8 Via Natural or Artificial Opening Endoscopic | Z No Device | Z No Qualifier |
| F Large Intestine, Right J Appendix | 0 Open 7 Via Natural or Artificial Opening 8 Via Natural or Artificial Opening Endoscopic | Z No Device | Z No Qualifier |
| F Large Intestine, Right J Appendix | 4
Percutaneous Endoscopic | Z No Device | G Hand-Assisted Z No Qualifier |
| G Large Intestine, Left L Transverse Colon M Descending Colon N Sigmoid Colon | 0 Open 7 Via Natural or Artificial Opening 8 Via Natural or Artificial Opening Endoscopic F Via Natural or Artificial Opening With Percutaneous Endoscopic Assistance | Z No Device | Z No Qualifier |
| G Large Intestine, Left L Transverse Colon M Descending Colon N Sigmoid Colon | 4 Percutaneous Endoscopic | Z No Device | G Hand-Assisted Z No Qualifier |
| R Anal Sphincter U Omentum | 0 Open 4 Percutaneous Endoscopic | Z No Device | Z No Qualifier |
This table shows the correct value for each character of the code. Hover your mouse over each column to see how we selected each value.
| Character 1 Section | Character 2 Body System | Character 3 Root Operation | Character 4 Body Part | Character 5 Approach | Character 6 Device | Character 7 Qualifier |
|---|---|---|---|---|---|---|
| Medical and Surgical | Gastrointestinal | Resection | Appendix | Percutaneous Endoscopic | No Device | No Qualifier |
| 0 | D | T | J | 4 | Z | Z |
Code Assignment for this Procedure: 0DTJ4ZZ
Character 1: Section
The first character identifies the broad procedure category or section where the code is found. In this example, 0 is the Medical and Surgical section in the first character.
Character 2: Body system
The second character identifies the body system. Body system refers to the general physiological system or anatomical region where the health care provider did the procedure. Examples of body systems include Tendons, Lower Arteries, and Central Nervous System and Cranial Nerves. In this example, D is the body system Gastrointestinal in the second character.
Character 3: Root operation
The third character identifies the root operation or goal of the procedure. Examples of root operations are Excision, Bypass, and Drainage. In this example, T is the root operation Resection in the third character.
Character 4: Body part
The fourth character identifies the body part or specific anatomical site where the health care provider did the procedure. The body system, which is the second character, gives only a general idea of the procedure site. The body part and body system values together give a precise description of the procedure site. Examples of body parts are Lower Arm and Wrist, Right; Kidney; and Tonsils. In this example, the body part value J is Appendix in the fourth character. When D, Gastrointestinal, appears in the second character and J, Appendix, appears in the fourth character, they're Gastrointestinal, Appendix.
Character 5: Approach
The fifth character identifies the approach or technique the health care provider used to reach the procedure site. The Medical and Surgical section includes 8 values to define the approach. Examples of approaches include open and percutaneous endoscopic. In this example, 4 is the Percutaneous Endoscopic approach in the fifth character.
Character 6: Device
The sixth character identifies the device. Some procedures need a device left in place at the end of the procedure. Device values fall into these 4 basic categories:
- Grafts and Prostheses
- Implants
- Simple or Mechanical Appliances
- Electronic Appliances
In this example, the value Z is No device in the sixth character.
Character 7: Qualifier
The seventh character identifies a qualifier, which specifies an added attribute of the procedure, if applicable. Examples of qualifiers include diagnostic and stereotactic. Qualifier choices vary depending on the previous values chosen. In this example, Z is No qualifier in the seventh character.