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Medical and Surgical Terms

Get definitions for terms found in the Medical and Surgical section used in ICD-10-PCS procedure codes. These definitions may also provide additional explanation or examples in their use.

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 first through fifth characters are always assigned a specific value, but the device (6th character) and the qualifier (7th character) are not applicable to all procedures.

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Medical and Surgical

Terms to Operation

Alteration
Modifying the anatomic structure of a body part without affecting the function of the body part
Principal purpose is to improve appearance

Includes:

  • Face lift, breast augmentation
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

Includes:

  • Coronary artery bypass, colostomy formation
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

Includes:

  • Urinary catheter change, gastrostomy tube change
Control
Stopping, or attempting to stop, postprocedural or other acute bleeding

Includes:

  • Control of post-prostatectomy hemorrhage, control of intracranial subdural hemorrhage, control of bleeding duodenal ulcer, control of retroperitoneal hemorrhage
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

Includes:

  • Creation of vagina in a male, creation of right and left atrioventricular valve from common atrioventricular valve
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

Includes:

  • Fulguration of rectal polyp, cautery of skin lesion
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

Includes:

  • Below knee amputation, disarticulation of shoulder
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

Includes:

  • Percutaneous transluminal angioplasty, internal urethrotomy
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

Includes:

  • Spinal cordotomy, osteotomy
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

Includes:

  • Thoracentesis, incision and drainage
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

Includes:

  • Partial nephrectomy, liver biopsy
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

Includes:

  • Thrombectomy, choledocholithotomy
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

Includes:

  • Dilation and curettage, vein stripping
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

Includes:

  • Extracorporeal shockwave lithotripsy, transurethral lithotripsy
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

Includes:

  • Spinal fusion, ankle arthrodesis
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

Includes:

  • Insertion of radioactive implant, insertion of central venous catheter
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

Includes:

  • Diagnostic arthroscopy, exploratory laparotomy
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

Includes:

  • Cardiac mapping, cortical mapping
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

Includes:

  • Fallopian tube ligation, ligation of inferior vena cava
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

Includes:

  • Reattachment of hand, reattachment of avulsed kidney
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

Includes:

  • Adhesiolysis, carpal tunnel release
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

Includes:

  • Drainage tube removal, cardiac pacemaker 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

Includes:

  • Colostomy takedown, suture of laceration
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

Includes:

  • Total hip replacement, bone graft, free skin graft
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

Includes:

  • Reposition of undescended testicle, fracture reduction
Resection
Cutting out or off, without replacement, all of a body part

Includes:

  • Total nephrectomy, total lobectomy of lung
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

Includes:

  • Esophagogastric fundoplication, cervical cerclage
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

Includes:

  • Adjustment of position of pacemaker lead, recementing of hip prosthesis
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

Includes:

  • Herniorrhaphy using mesh, mitral valve ring annuloplasty, put a new acetabular liner in a previous hip replacement
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

Includes:

  • Tendon transfer, skin pedicle flap transfer
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

Includes:

  • Kidney transplant, heart transplant