Determining the ICD-10-PCS Code
Coding Example 4
Procedure: Bypass trachea to cutaneous with tracheostomy device, open approach
Click the Index tab to find the first 3 values of the code. Then, click the Table 0B1 tab to see the value choices for characters 4-7 of the code. Click the Character Section Table tab to see the correct 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 for Tracheostomy in the Index for the type of procedure. The subterm Bypass, Respiratory System directs the user to Table 0B1 to complete the code.
Tracheostomy see Bypass, Respiratory System 0B1
Step 2: Locate Table 0B1, which shows the possible value choices for the last 4 characters of the code. All 7 characters are needed to complete the code.
| Body Part | Approach | Device | Qualifier |
|---|---|---|---|
| 1 Trachea | 0 Open | D Intraluminal Device | 6 Esophagus |
| 1 Trachea | 0 Open | F Tracheostomy Device Z No Device | 4 Cutaneous |
| 1 Trachea | 3 Percutaneous 4 Percutaneous Endoscopic | F Tracheostomy Device Z No Device | 4 Cutaneous |
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 | Respiratory | Bypass | Trachea | Open | Tracheostomy Device | Cutaneous |
| 0 | B | 1 | 1 | 0 | F | 4 |
Code Assignment for this Procedure: 0B110F4
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 performed the procedure. Examples of body systems include Tendons, Lower Arteries, Central Nervous System, and Cranial Nerves. In this example, B is the body system Respiratory in the second character.
Character 3: Root operation
The third character identifies the root operation or objective of the procedure. Examples of root operations are Excision, Bypass, and Drainage. In this example, 1 is the root operation Bypass in the third character.
Character 4: Body part
The fourth character identifies the body part or specific anatomical site where the health care provider performed 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 1 is Trachea in the fourth character. When B, Respiratory, appears in the second character and 1, Trachea, appears in the fourth character, they're Respiratory, Trachea.
Character 5: Approach
The fifth character identifies the approach, or technique 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, 0 is the Open 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 F is Tracheostomy 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, 4 is Cutaneous in the seventh character.