ICD-10-PCS Fifth Character: The Approach

Do you struggle when coding the approach of a surgery on a PCS code?  Try using the following definitions, examples, and thought processes.

The fifth digit of a PCS code identifies the technique or approach used to reach the procedure site.  There are seven different approaches each with their own unique value, as follows:

1. X – External
2. O – Open
3. 3 – Percutaneous
4. 4 – Percutaneous Endoscopic
5. 7 – Via natural or artificial opening
6. 8 – Via natural or artificial opening endoscopic
7. F – Via natural or artificial opening with percutaneous endoscopic assistance

An external approach describes a procedure performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane. Examples: closed reduction of fracture, resection of tonsils.

An open approach involves cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure.  Examples: abdominal hysterectomy, open CABG.

A percutaneous approach is entry by puncture or minor incision of instrumentation through the skin or mucous membrane and/or any other body layers necessary to reach the site of the procedure. Examples: needle biopsy of liver, peritoneal drainage.

A percutaneous endoscopic approach is entry by puncture or minor incision of instrumentation through the skin or mucous membrane and/or any other body layers necessary to reach and visualize the site of the procedure. Examples:  knee arthroscopy, laparoscopic cholecystectomy.

Via natural or artificial opening approach is entry of instrumentation through a natural or artificial external opening to reach the site of the procedure. Examples: Foley catheter placement, endotracheal intubation.

Via natural or artificial opening endoscopic approach is entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure. Examples: colonoscopy, hysteroscopy.

Via natural or artificial opening with percutaneous endoscopic assistance is 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. Examples: laparoscopic-assisted ####### hysterectomy.

Still lost? Try using this decision tree below:

As a last resort, if the documentation is unclear, it is really best practice to research and/or query. Learn all about ICD-10 coding with CareerStep’s medical coding training.