ICD-10 Code
International Classification of Diseases, 10th Revision
Jan 24, 2017

Procedure Terms used in “Medical and Surgical”

The medical and surgical section codes represent the vast majority of procedures reported in an inpatient setting. Medical and surgical procedure codes have a first character value of "0". The 2nd character indicates the general body system (e.g., gastrointestinal). The 3rd character indicates the root operation, or specific objective, of the procedure (e.g., excision). The 4th character indicates the specific body part on which the procedure was performed (e.g., duodenum). The 5th character indicates the approach used to reach the procedure site (e.g., open). The 6th character indicates whether any device was used and remained at the end of the procedure (e.g., synthetic substitute). The 7th character is a qualifier that may have a specific meaning for a limited range of values.

The 1st through 5th characters are always assigned a specific value, but the device (6th character) and the qualifier (7th character) are not applicable to all procedures. The value Z is used for the 6th and 7th characters to indicate that a specific device or qualifier does not apply to the procedure.

The body systems for medical and surgical section codes are specified in the second character. In order to provide necessary detail, some body systems are subdivided. For example, body system values K (muscles), L (tendons), M (bursae and ligaments), N (head and facial bones), P (upper bones), Q (lower bones), R (upper joints) and S (lower joints) are divisions of the musculoskeletal system.


Terms for Medical and Surgical

Alteration
Modifying the anatomic structure of a body part without affecting the function of the body part

Principal purpose is to improve appearance

Bypass
Altering the route of passage of the contents of a tubular body part

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

Change
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

All CHANGE procedures are coded using the approach EXTERNAL

Control
Stopping, or attempting to stop, postprocedural or other acute bleeding

The site of the bleeding is coded as an anatomical region and not to a specific body part

Creation
Putting in or on biological or synthetic material to form a new body part that to the extent possible replicates the anatomic structure or function of an absent body part

Used for gender reassignment surgery and corrective procedures in individuals with congenital anomalies

Destruction
Physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent

None of the body part is physically taken out

Detachment
Cutting off all or a portion of the upper or lower extremities

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

Dilation
Expanding an orifice or the lumen of a tubular body part

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

Division
Cutting into a body part, without draining fluids and/or gases from the body part, in order to separate or transect a body part

All or a portion of the body part is separated into two or more portions

Drainage
Taking or letting out fluids and/or gases from a body part

The qualifier DIAGNOSTIC is used to identify drainage procedures that are biopsies

Excision
Cutting out or off, without replacement, a portion of a body part

The qualifier DIAGNOSTIC is used to identify excision procedures that are biopsies

External
When used as Approach
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
Extirpation
Taking or cutting out solid matter from a body part

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

Extraction
Pulling or stripping out or off all or a portion of a body part by the use of force

The qualifier DIAGNOSTIC is used to identify extraction procedures that are biopsies

Fragmentation
Breaking solid matter in a body part into pieces

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

Fusion
Joining together portions of an articular body part rendering the articular body part immobile

The body part is joined together by fixation device, bone graft, or other means

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
Inspection
Visually and/or manually exploring a body part

Visual exploration may be performed with or without optical instrumentation. Manual exploration may be performed directly or through intervening body layers

Map
Locating the route of passage of electrical impulses and/or locating functional areas in a body part

Applicable only to the cardiac conduction mechanism and the central nervous system

Occlusion
Completely closing an orifice or the lumen of a tubular body part

The orifice can be a natural orifice or an artificially created orifice

Open
When used as Approach
Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure
Percutaneous
When used as Approach
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
When used as Approach
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
Reattachment
Putting back in or on all or a portion of a separated body part to its normal location or other suitable location

Vascular circulation and nervous pathways may or may not be reestablished

Release
Freeing a body part from an abnormal physical constraint by cutting or by the use of force

Some of the restraining tissue may be taken out but none of the body part is taken out

Removal
Taking out or off a device from a body part

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

Repair
Restoring, to the extent possible, a body part to its normal anatomic structure and function

Used only when the method to accomplish the repair is not one of the other root operations

Replacement
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

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

Reposition
Moving to its normal location, or other suitable location, all or a portion of a body part

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

Resection
Cutting out or off, without replacement, all of a body part
Restriction
Partially closing an orifice or the lumen of a tubular body part

The orifice can be a natural orifice or an artificially created orifice

Revision
Correcting, to the extent possible, a portion of a malfunctioning device or the position of a displaced device

Revision can include correcting a malfunctioning or displaced device by taking out or putting in components of the device such as a screw or pin

Supplement
Putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part

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

Transfer
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

The body part transferred remains connected to its vascular and nervous supply

Transplantation
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

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

Via Natural or Artificial Opening
When used as Approach
Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure
Via Natural or Artificial Opening Endoscopic
When used as Approach
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
When used as Approach
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
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When ICD 10 was implemented on October 1, 2015, it did not affect physicians', outpatient facilities', and hospital outpatient departments' use of CPT codes on Medicare Fee-For-Service claims. Providers should continue to use CPT codes to report these services.