ICD-10-CM/PCS – Part 60: Question & Answer

ICD-10-CM/PCS – Part 60: Question & Answer

Coding Tidbits Written By: Linda Kobayashi
Edited and Posted By: Andrea Wong

 

Hi There, Busters. Andrea and Linda wish you the best as you prepare for ICD-10. For the past few months we have focused on problems in the Med/Surg section. We thought it would be helpful to review other sections of the PCS coding book. Over the next several weeks we will cover Placement, Administration, Measuring and Monitoring and Extracorporeal Assistance and Performance. Today’s lesson focuses on the Placement section.

This Week’s Coding Problem:

The patient, an avid skier, slammed into a tree and sustained a nondisplaced comminuted fracture of the shaft of his left fibula. His physician ordered traction to ease the pain while waiting for surgery. His physician noted that surgery might possibly be avoided by the application of mechanical traction in which a traction apparatus is applied.

 

 

 

 

 

 

 

 

Who We Are

 

 

 

 

 

 

 

 

 

Answer Key:

  • S82.455A = Nondisplaced comminuted fracture of shaft of left fibula, initial encounter for closed fracture.
  • 2W6RX0Z = Traction of left lower leg using traction apparatus

 

Breakdown of S82.455A:

  • S82 = Fracture of lower leg, including ankle
  • S82.4 = Fracture of shaft of fibula
  • S82.45 = Comminuted fracture of shaft of fibula
  • S82.455 = Nondisplaced comminuted fracture of shaft of left fibula
  • S82.455A = Initial encounter for closed fracture

 

To locate S82.455A: Disease Index > Fracture, traumatic > fibula (shaft, styloid) > comminuted > nondisplaced > S82.45- > Comminuted fracture of shaft of fibula > S82.455 > Nondisplaced comminuted fracture of left fibula > 7th character required > S82.455A > Initial encounter.

Comments:

  • Non-displaced fractures are typically clean breaks to the bone; usually only a crack in the bone that does not go all the way through. They differ from displaced fractures because a displaced fracture normally results in a complete break and shifts the bone from its original place, sometimes so much that it protrudes from the body (open fracture).
  • A comminuted fracture is a fracture in which the bone involved in the fracture is broken into several pieces. At least three separate pieces of bone must be present for a fracture to be classified as comminuted.

To locate 2W6RX0Z: PCS Index > Traction > Leg > Lower > Left > 2W6RX > locate table 2W6 and go across the row to verify that the characters RX are correct and then finish building the code:

Traction of Left Lower Leg Using Traction Apparatus

PCS Root Ops 60
Comments:

  • Placement procedures involve services performed without making any incision or puncture.
  • Definition of traction: Exerting a pulling force on a body region in a distal direction.
  • Traction is the use of weights, ropes and pulleys to apply force to tissues surrounding a broken bone.
  • It’s sometimes used to keep a broken leg in the correct position during the early stages of healing, or to ease the pain of a fracture while a person is waiting for surgery.
  • All 7 characters retain the same meaning in both the Med/Surg section and the Placement section, but the root operations in the Placement section differ from those in the Med/Surg section.
  • The root operations in the Placement section include only those procedures that are performed without making an incision or a puncture.

Directions for Locating the Codes by Going Directly to the Tables

Traction of Left Lower Leg

2W6RX0Z

  1. Step #1 is to locate the correct section in your PCS coding book. You know that the root operation is traction. This is a tough one. Go to the beginning of your PCS coding book (I’m basing this on the Optum PCS coding book) in which the various sections are explained and look for the Placement section. The character value is always 2.
  2. Step 2: Determine the correct Body System. Stay in the Placement section. Under the Placement section, the character meanings are given. The Body System for the Placement section states that the second character contains two values specifying either Anatomical Regions or Anatomical Orifices. Obviously it isn’t anatomical orifices, so that leaves us with Anatomical Regions with a character value of W. We have our first two characters, 2W.
  3. Step 3: Determined the root operation. The root operations are listed alphabetically. Go through all the tables that start with 2W, looking for the root operation, Traction. This is a fairly easy step because all you have to do to find Traction is to scan through all the tables starting with 2W. Traction has a character value of 6. We now have 2W6, our first 3 characters.
  4. Step 4: Determine the body part. That should be easy enough because you know it involves the lower leg, which has a character value of R. We’re up to 4 characters, 2W6R.
  5. Step 5: Determine the approach. As you now know, root operations in the Placement section include only those procedures that are performed without making an incision or a puncture. Therefore the approach is external. Also note that the approach in table 2W6 only lists External. We are now up to 5 characters, 2W6RX
  6. Step 6: Determine if there is a device left in place. Yes there is the traction apparatus, with a character value of 0. We now have 6 characters, 2W6RX0.
  7. Step 7: Determine the qualifier. In our scenario, there is no qualifier, so once again we assign the placeholder of Z for a code of 2W6RX0Z.

Coding Tidbits Written By: Linda Kobayashi
Edited and Posted By: Andrea Wong

 

Problem for this week:

A 55-year-old man was diagnosed with coronary artery disease of 3 coronary arteries. He undergoes coronary artery bypass surgery (CABG) using 3 saphenous vein grafts to the aorta, with cardiopulmonary bypass.

 

 

 

 

 

 

 

 

Who We Are

 

 

 

 

 

 

 

 

 

Answer Key:

  • I25.10 = Atherosclerotic heart disease of native coronary artery without angina pectoris
  • 021209W = Bypass coronary artery, 3 sites from aorta with autologous venous tissue, open approach
  • 5A1221Z = Performance of cardiac output, continuous

 

To Locate:

  • I25.10: Index > Arteriosclerosis, arteriosclerotic > coronary (artery)

To Locate 021209W: Px index > Bypass > Artery > Coronary > 3 sites > 0212 > go to table 021 and go across the row to assign the remaining characters:

Bypass coronary artery, 3 sites from aorta with autologous venous tissue, open approach

PCS Root Ops 59 Comments:

  • Bypass is defined in ICD-10-PCS as “Altering the route of passage of the contents of a tubular body part.”
  • Guideline B3.6b: Coronary arteries are classified by the number of distinct sites treated, rather than the number of coronary arteries or anatomical name of a coronary artery involved (eg, left anterior descending). Coronary artery bypass procedures are coded differently from other bypass procedures: The body part identifies the # of coronary arteries sites bypassed to, and the qualifier specifies the vessel bypassed from.
  • In our example, aortocoronary artery bypass of 3 sites is classified in the body part axis of classification as a value of 2, for 3 coronary artery sites, and the qualifier specifies the aorta as the body part bypassed from with the value of W. Think of it as the number of coronary arteries with bypass grafts from the aorta to the coronary arteries.
  • The saphenous vein is removed from the patients own leg and one end of the saphenous vein graft is sewn to the largest artery in the body (aorta) and the other end is sewn past the obstruction into the coronary artery.

 

To Locate 5A1221Z: Px index > Performance > Cardiac > Continuous Output > 5A1221Z: locate table 5A1 and verify that the code is correct:

Performance of cardiac output, continuous

PCS Root Ops 59B Comments:

  • Values for 5A1221Z: This section, Extracorporeal Assistance and Performance, covers such procedures as cardiopulmonary bypass procedures, ventilator management, hyperbaric wound therapy and hemodialysis. The root operation, Performance, means completely taking over a physiological function by extracorporeal means. Duration, the 5th character value, describes whether the procedure was performed on a single occasion or multiple occasions. The 6th character value, Function, refers to cardiac output during the procedure.
  • A&P: Cardiopulmonary bypass is a technique that mechanically circulates and oxygenates blood from the body while bypassing the heart and lungs.

 

Directions for Locating the Codes by Going Directly to the Tables

CABG with autologous venous tissue, 3 sites, open approach

021209W

  1. Step 1: Locate the correct section in your PCS coding book. You know that surgery was performed, so the most logical selection is the Med/Surg section. The majority of procedures are located in the Med/Surg section. The first character in this section is always 0.
  2. Step 2: Determine the correct Body System. You know that 3 of the coronary arteries underwent a bypass, so it should be apparent that the Heart and Great Vessels should be assigned as the 2nd You should now have two characters, 02.
  3. Step 3: Determined the root operation. The root operations are listed alphabetically. Go through the all the tables that start with 02 looking for the root operation, Bypass (1). This is a fairly easy step because all you have to do to find “Bypass” is to scan through all the 02 tables alphabetically. So far we have values 021.
  4. Step 4: Code selection is based on the number of coronary artery sites treated using the 4thcharacter, body part value to indicate coronary artery at one site, two sites, etc. Coronary arteries are classified by the number of distinct sites treated rather than the number of coronary arteries or the anatomic name of a coronary artery. We now have the characters 0212.
  5. Step 5: The approach for performing a CABG is open. So far we have 02120.
  6. Step 6: Determine if there is a device left in place. As you well know, this procedure involves 3 saphenous vein grafts to the aorta. The saphenous vein is an autologous venous tissue graft because it is taken from the patient’s own leg. So now we have our code 021209.
  7. Step 7: Determine if there is a qualifier. The qualifier indicates the location of where the bypass is originating from which, medically speaking, is from the Aorta (W) to the coronary arteries. The code is now complete as 021209W.

Coding Tidbits Written By: Linda Kobayashi
Edited and Posted By: Andrea Wong

 

We’re on countdown for ICD-10. Check out this week’s tidbit and learn how to code embolization of a uterine artery.

Problem for this week:

The patient was diagnosed with intramural leiomyoma (fibroids) of the uterus. She underwent a pelvic exam and a hysteroscopy with biopsies as an outpatient. Based on the results, she was admitted to the acute care setting for percutaneous embolization of the right uterine artery, using coils. In addition to the fibroids, she has also been experiencing post-menopausal bleeding.

 

 

 

 

 

 

 

 

Who We Are

 

 

 

 

 

 

 

 

 

Answer Key:

  • D25.1 = Intramural leiomyoma of uterus
  • N95.0 = Postmenopausal bleeding
  • 04LE3DT = Occlusion of right uterine artery with intraluminal device, percutaneous approach

To Locate D25.0: Disease Index > Leiomyoma > uterus > intramural

To Locate N95.0: Disease Index > Bleeding > Post-menopausal

To Locate 04LE3DT: PCS Index > Embolization > see Occlusion > Artery > There is no listing in the Index for uterine artery or internal iliac artery. This is a good example of when you must use the tables to code this problem correctly. Once you locate the correct table, code the procedure:

Occlusion of Right Uterine Artery with Intraluminal Device, Percutaneous Approach

PCS Root Ops 58 

Comments:

  • Occlusion: Completely closing an orifice or the lumen of a tubular body part.
  • Body System: The diaphragm is the dividing line between upper and lower arteries.
  • Body Part: Where did the internal iliac artery come from? The uterine artery usually arises from the anterior division of the internal iliac artery. It travels to the uterus crossing the ureter anteriorly, reaching the uterus by traveling in the cardinal ligament. The cardinal ligament is a major ligament of the uterus. It is located at the base of the broad ligament of the uterus.
  • Embolization uterine/internal iliac artery (UAE): This relatively new treatment is an alternative to open surgery for fibroids. Embolization is a technique that blocks the blood flow to the fibroid(s), causing them to shrink and die. This also often decreases menstrual bleeding and symptoms of pain, pressure, urinary frequency or constipation. In other words, embolization is a therapeutic introduction of a substance into a vessel in order to occlude it.
  • Device: The coils are an embolic agent that helps block blood flow. The coils are considered to be an intraluminal device. Devices that remain in the patient post-operatively must be coded.
  • Qualifier: Qualifiers contain unique values for individual procedures. For example, the qualifier can be used to identify the destination site in a bypass. In our example the qualifier indicates the type of artery (uterine) as well as laterality.

 

Directions for Locating the Codes by Going Directly to the Tables

Embolization of Right Uterine Artery

04LE3DT

  1. Step #1 is to locate the correct section in your PCS coding book. You know that surgery was performed, so the most logical selection is the Med/Surg section. The majority of procedures are located in the Med/Surg section. The first character in this section is always 0.
  2. Step 2: Determine the correct Body System. You know that the target organ is a uterine artery. You also know that the diaphragm divides upper and lower arteries. Since it is a lower artery (any arteries below the diaphragm), you should go to the Lower Arteries section. Lower arteries are assigned the character value of 4. We now have the 1st 2 characters, 04.
  3. Step 3: Determined the root operation. The root operations are listed alphabetically. Go through all the tables that start with 04, looking for the root operation, Occlusion (L). This is a fairly easy step because all you have to do to find “Occlusion” is to scan through all the tables starting with 04. We now have 04L.
  4. Step 4: Determine the body part. This one is a bit tricky. The body part is the uterine artery but the 04L table doesn’t list it. How do you know that you should assign the internal iliac artery as the correct body part? You don’t necessarily know, so if you don’t, pull out that anatomy book. We now have the characters 04LE.
  5. Step 5: The approach, as stated in our diagnostic statement, is percutaneous. So far we have characters 04LE3.
  6. Step 6: Determine if there is a device left in place. Yes, the coils are a type of embolic agent. Any device that remains in the patient post-operatively should be coded. We now have characters 04LE3D.
  7. Step 7: Determine the qualifier, the right uterine artery, T. We now have our code, 04LE3DT.

Coding Tidbits Written By: Linda Kobayashi
Edited and Posted By: Andrea Wong

 

Problem for this week:

The patient, a 70-year-old gentleman, saw his doctor complaining of chest pain. He has a history of coronary artery disease for which he has been on Nitroglycerine for several years. He also has a history of smoking 3 packs per day with no intention of quitting or cutting down. A heart catheterization done two days ago in the outpatient setting showed that there was atherosclerosis in his left anterior descending (LAD) coronary artery, native vessel. Due to his cardiac history along with his angina and smoking, he was admitted and underwent a PTCA of the LAD with insertion of a drug-eluting stent. To reach the targeted site, the procedure was done percutaneously.

 

 

 

 

 

 

 

Who We Are

 

 

 

 

 

 

 

 

 

Answer Key:

  • I25.119: Atherosclerotic heart disease of native coronary artery with unspecified

               angina pectoris

  • F17.210 = Nicotine dependence, cigarettes, uncomplicated
  • 027034Z: Dilation of coronary artery, one site with drug-eluting intraluminal

                 device, percutaneous approach

 

Breakdown of I25.119:

  • I25 = Chronic ischemic heart disease
  • I25.1 = Atherosclerotic heart disease of native coronary disease
  • I25.11 = Atherosclerotic of native coronary artery with angina pectoris
  • I25.119 = Atherosclerotic of native coronary artery with unspecified angina pectoris

 

To locate I25.119: Disease Index > Atherosclerosis (see also Arteriosclerosis) > coronary > artery > with angina pectoris > see Arteriosclerosis, coronary (artery) > native vessel > with > angina pectoris > I25.119.

Comments for I25.119:

  • ICD-10-CM has combination codes for atherosclerotic heart disease with angina pectoris. One of the subcategories for this code is I25.11, Atherosclerotic heart disease of native coronary artery with angina pectoris.
  • When using this combination code it is not necessary to use an additional code for angina pectoris. A causal relationship can be assumed in a patient with both atherosclerosis and angina pectoris, unless the documentation indicates the angina is due to something other than the atherosclerosis.

 

To locate F17.210: Disease Index > Dependence > drug > nicotine > cigarettes > F17.210

To Locate 027034Z: PCS Index > PTCA (percutaneous transluminal coronary angioplasty) > see Dilation, Heart and Great Vessels > 027 > Artery > Coronary > One Site > 0270 > Locate table 027 and go across the row to finish building the code as well as verify that the 4th character, “0” is correct:

Dilation of Coronary Artery, One Site with Drug-eluting Intraluminal Device, Percutaneous Approach

PCS Root Ops 57

Comments:

  • The Index instructs us to see Dilation of Heart and Great Vessels, but there is no subterm under Dilation for Heart/Great Vessels, so what do you do? Stay with the main term, Dilation, and then look for the subterm, Coronary. From there, you should easily find the code in the code.
  • Dilation: Expanding an orifice or the lumen of a tubular body part.
  • PTCA is a minimally invasive procedure to open up blocked coronary arteries, allowing blood to circulate unobstructed to the heart muscle.
  • Once the guidewires and catheters are in place, a balloon catheter is advanced to the blockage site. The balloon is inflated for a few seconds to compress the blockage site against the artery wall. Then the balloon is deflated and pulled out.

Directions for Locating the Codes by Going Directly to the Tables

PTCA of the LAD with Insertion of a Drug-Eluting Stent

027034Z

  1. Step #1 is to locate the correct section in your PCS coding book. You know that surgery was performed, so the most logical selection is the Med/Surg section. The majority of procedures are located in the Med/Surg section. The first character in this section is always 0.
  2. Step 2: Determine the correct Body System. You know that the one of the coronary arteries underwent insertion of a drug-eluting stent, so it should be apparent that the Heart and Great Vessels should be assigned as the 2nd You should now have two characters, 02.
  3. Step 3: Determined the root operation. The root operations are listed alphabetically. Go through the all the tables that start with O2 looking for the root operation, Dilation (7). This is a fairly easy step because all you have to do to find “Dilation” is to scan through all the 02 tables alphabetically.
  4. Step 4: Code selection is based on the number of coronary artery sites treated using the 4th character, body part value to indicate coronary artery at one site, two sites….coronary arteries are classified by the number of distinct sites treated rather than the number of coronary arteries or the anatomic name of a coronary artery, as in our scenario – LAD. We now have the characters 0270.
  5. Step 5: The approach, as stated in our diagnostic statement, is percutaneous. So far we have 02703.
  6. Step 6: Determine is there is a device left in place. As you well know, it is a drug-eluting stent. So now we have our code 027034.
  7. Step 7: Determine if there is a qualifier. There is no qualifier, so the 7th character is Z. The code is now complete as 027034Z.

Coding Tidbits Written By: Linda Kobayashi
Edited and Posted By: Andrea Wong

 

Problem for this week:

The patient, a 10-year-old boy, sustained a severe injury to his little finger. As he was getting out of the car someone inadvertently slammed the door on him. Due to the severity of the injury, the finger on his left hand could not be saved. He underwent a fifth ray carpometacarpal joint amputation, left hand, open approach.

 

 

 

 

 

 

 

 

 

 

Who We Are

 

 

 

 

 

 

 

 

 

Answer Key:

S68.117A – Complete traumatic transphalangeal amputation of left little finger

0X6K0Z8 – Detachment at left hand, complete 5th ray, open approach

 

Breakdown of S68.117:

  • S68 = Traumatic amputation of wrist, hand and fingers
  • S68.1 = Traumatic metacarpophalangeal amputation of other and unspecified finger
  • S68.11 = Complete traumatic metacarpophalangeal amputation of other and unspecified finger
  • S68.117 = Complete traumatic metacarpophalangeal amputation of left little finger

 

To locate S68.117A:  Disease Index > Wound, open > finger(s) > with > amputation > see Amputation, traumatic, finger (complete) (metacarpophalangeal) > little finger > S68.11- > go to Tabular to assign 7th character > A (initial encounter) > S68.117A.

Comments:

  • I found this one with some difficulty, as there are many main terms from which to select the most appropriate one.
  • A dash immediately following the partial code in the Disease Index means that one or more characters are needed to complete the code. How do you know which encounter to assign?
  • There is a 7th character box just below category S68 listing the encounters: “A” for initial encounter; “D” for subsequent encounter; “S” for sequela. There is nothing in the diagnostic statement to indicate that this is for a subsequent encounter.

 

To locate 0X6K0Z8: PCS Index > Amputation > see Detachment > Hand > Left > 0X6K0Z > locate table 0X6 and then go across the row to (1) Verify that the 6 digits are correct > (2) Assign the 7th digit:

Detachment at Left Hand, Complete, Open Approach

PCS Root Ops 56

Comments:

  • Here we have another example of some of ICD-10-CM’s terminology changes, with Detachment replacing Amputation.
  • Definition of Detachment: Cutting off all or a portion of the upper or lower extremities.
  • A complete ray amputation is through the carpometacarpal joint.

 

Directions for Locating Codes from the Tables

Amputation of Left Little Finger

0X6K0Z8

  1. Step #1 is to locate the correct section in your PCS coding book. You know that surgery was performed, so the most logical selection is the Med/Surg section. The majority of procedures are in the Med/Surg section. The first character in the Med/Surg section is always 0.
  2. Step 2: Determine the correct Body System. The Body System and the Body Part should reinforce each other. We know it involves the hand and the hand is an upper extremity. You should now have two characters, 0X.
  3. Step 3: Determined the root operation. The root operations are listed alphabetically. Go through the all the tables that start with 0X and look for the root operation, Detachment. We now have the first three characters, 0X6, which puts us in the correct table. The first 3 character values are always listed for you at the top of the table. It gives the section, Med/Surg; the body system, Anatomical Regions/Upper Extremities; the root operation, Detachment.
  4. Step 4: Identify the Body Part to determine the 4th character value. The Body Part, hand, should relate to the root operation, Detachment because it was the little finger of the left hand that was detached. We now have 4 character values 0X6K.
  5. Step 5: Determine the Approach. No guesswork regarding the approach, as our diagnostic statement clearly states that the procedure was done via an open approach. We should now have 5 characters, 0X6K0
  6. Step 6: Determine whether or not a device was left in the patient postoperatively. No device was left in place, so assign Z, the placeholder, as the character value. We should now have 6 characters, 0VT00Z.
  7. Step 7: The qualifier, 8, indicates that the entire 5th ray/little finger was detached. We now have our code, 0X6K0Z8.

Coding Tidbits Written By: Linda Kobayashi
Edited and Posted By: Andrea Wong

 

The clock is ticking – we are on countdown for ICD-10. Very few of us are ICD-10 coding experts, but with determination and dedication, we will all get there, some of us sooner than later. Several coders intend to retire come October. Please don’t let ICD-10 discourage you. Everyone faces a challenge learning how to code ICD-10 procedures, a complete change from the ICD-9 procedure code set. On a lighter note, the ICD-10-CM diagnostic codes follow similar publication layout/format as ICD-9-CM. There, of course, have been changes to the structure of the ICD-10-CM codes, but none that are all that difficult to learn. Remember this – inch by inch, it’s a cinch. We are all in this together.

 

There are a few issues we would like to point out for our new readers. Most of you know from previous Tidbits that you are given problems that require assignment of both diagnosis and procedure codes. We will continue to offer this feature for all future Tidbits. The breakdown of diagnostic codes, a relatively new feature, applies only to the PDx. Also, the sequencing of directions for using the tables will now be placed immediately under the principal procedure table rather than placing it as the last item.

 

Before coding this week’s problem, please note the following: Subsequent encounter for open and closed fractures: used for encounters after active fracture treatment has been completed and the patient is receiving routine care during the healing or recovery period.

 

Problem for this week:

Several months ago the patient, a 55-year-old woman, fell off a ladder and fractured her left hip. She sustained a closed fracture of the femoral shaft for which she underwent surgery. During her recovery period, she saw her physician complaining of pain in her hip. After x-rays were taken, the physician diagnosed her with non-union of the fracture. Her treatment consisted of a percutaneous insertion of a bone growth stimulator. Do not assign E codes with the exception of the external cause of the fall.

 

 

 

 

 

 

 

 

 

Who We Are

 

 

 

 

 

 

 

 

 

Answer Key:

  1. S72.302K: Unspecified fracture of shaft of left femur, subsequent encounter for closed fracture with non-union
  2. W11.XXXD: Fall on and from ladder, subsequent encounter
  3. 0QHY3MZ: Insertion of bone growth stimulator into lower bone, percutaneous approach

 

Breakdown of S72.302K:

S72 = Fracture of femur

S72.3 = Fracture of shaft of femur

S72.30 = Unspecified fracture of shaft of femur

S72.302 = Unspecified fracture of shaft of left femur

S72.302K = Unspecified fracture of shaft of left femur, subsequent encounter for closed fracture with non-union

 To locate S72.302K: Disease Index > Fracture, traumatic > femur, femoral > shaft > S72.30- > Tabular to complete code > left > S72.302 > 7th character required > K > S72.302K

Comments for S72.302K:

  • Under S72, Fracture of femur, there is a box containing all the 7th character possibilities.
  • K is the 7th character – subsequent encounter for closed fracture with nonunion.
  • A dash following a character as in S72.30- indicates that the code is incomplete and you must refer to the Tabular to complete the code.
  • Nonunion means the fracture has failed to show evidence of healing and there is still separation of bony structures involved in the fracture.

 

To locate W11.XXXD: External Causes Index > Fall, falling > from, off, out of > ladder > W11 > go to Tabular to complete the code > see the box immediately below W11 to select the appropriate encounter > D, subsequent encounter for a code of W11.XXXD.

Comments for W11.XXXD:

  • This is a subsequent encounter as indicated in the diagnostic statement.
  • ICD-10-CM codes are always up to 7 digits in length. How do you account for the 3 Xs? Xs serve as placeholders in ICD-10-CM.
  • Certain ICD-10-CM categories have applicable 7th characters and is required for all codes within the category, or as the notes in the Tabular List instruct. If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters. In our scenario we have 3 Xs to fill in the empty characters.

 

To locate 0QHY3MZ: PCS Index > Insertion of device in > Bone > Femoral Shaft > Left > 0QHY > locate table 0QH and go across the row to finish building the code:

Insertion of Bone Growth Stimulator into Lower Bone, Percutaneous Approach

PCS Root Ops 55

Comments:

  • Insertion is defined as “Putting in a non-biological appliance that monitors, assists, performs or prevents a physiological function but does not physically take the place of a body part.”
  • This device (BGS) stimulates the natural healing process by sending low-level pulses of electromagnetic energy to the injury or fusion site.
  • This problem can be a bit tricky. When indexing Insertion of device in, there is also a subterm for Femoral Shaft (0QH9.) When reviewing the table, Femoral Shaft, Left (9) is not an option for the bone growth stimulator (BGS). In the table row for BGS (M) is the only 6th character device available under the body part for the Lower Bone (Y).
  • The diaphragm is used as the frame of reference for body systems classified as upper bones or lower bones. In our scenario, the femur is below the diaphragm and considered to be the part of the Lower Bones.
  • If you look at Devices in the 2nd row of table 0QH, it doesn’t include a choice of BGS. The 3rd row of table 0QH does list BGS; therefore, you have no options to use any row in that table except for row #3.
  • Guideline B6.1a: A device is coded only if a device remains after the procedure is completed. If no device remains, the device value, No Device, is coded.

Directions for Locating the Codes by Going Directly to the Tables

Insertion of Bone Growth Stimulator

0QHY3MZ

  1. Step #1 is to locate the correct section in your PCS coding book. You know that surgery was performed, so the most logical selection is the Med/Surg section. The majority of procedures are found here. The first character in the Med/Surg section is always 0.
  2. Step 2: Determine the correct body system. The body system is Lower Bones. Don’t look for a section entitled Musculoskeletal System. ICD-10-PCS uses Upper Bones and Lower Bones instead of the broader Musculoskeletal System anatomy (muscles, tendons, bursae and ligaments, head and facial bones, upper and lower joints, upper and lower bones, and in our scenario, lower bones.) We have identified the first two characters, 0Q.
  3. Step 3: Determine the root operation. You know you have to be in a table that starts with 0Q. You should also know that the root operations are listed alphabetically. Simply go through all the tables that start with 0Q and look for the root operation, Insertion. We now have the first three characters, 0QH, which puts us in the correct table. The first 3 character values are always listed for you at the top of the table. It gives the section, Med/Surg; the body system, Lower Bones; the root operation, Insertion.
  4. Step 4: Identify the body part to determine the 4th character value. The body part, left femoral shaft, should relate to the root operation, Insertion, because it was the femoral shaft that received the Bone Growth Stimulator. However, as we previously discussed, since the device, bone growth stimulator is not an option in row #2, you must use row #3 to capture Bone Growth Stimulator. Row #3 lists only one body part, Lower Bone. We now have 4 character values, 0QHY.
  5. Step 5: Determine the Approach. No guesswork regarding the approach, as our diagnostic statement clearly states that the procedure was done percutaneously. We should now have 5 characters, 0QHY3.
  6. Step 6: Determine whether or not a device was left in the patient postoperatively. We know that there was a device left in place, the Bone Growth Stimulator. We should now have 6 characters, 0QHY3M.
  7. Step 7: There is no qualifier, so we should now have our code, 0QHY3MZ. Z functions as a placeholder in ICD-10-PCS. Z is to PCS what X is to ICD-10-CM.

Coding Tidbits Written By: Linda Kobayashi
Edited and Posted By: Andrea Wong

 

Hello there, Busters. In a few more months we will all be coding from the ICD-10 code set, ready or not. We hope these weekly tidbits have been helpful. We’re trying to do our best to help you prepare. This week we are giving you two problems to solve related to the prostate. It is a good exercise because when coding, you will be able to compare the similarities and differences between the 2 coding problems.

There are a few changes we are going to point out for our new readers. For the past few weeks we have given you coding problems that require assignment of both diagnoses and procedures. With respect to the breakdown of diagnostic codes, a new feature, we will only do that for the PDx. However, this week’s PDx only has 3 digits, so there is nothing to break down. This week you will be given 2 problems to solve from Diseases of the Genitourinary System, Chapter 14. Also, directions for locating the codes by using the tables only applies to the principal procedure and for this week, it will be for the second problem, and will be the last item discussed.

Problems for the week:

1.) A 55-year-old man was anuric and diagnosed with prostate cancer for which he underwent an open radical retropubic prostatectomy.

2.) A resident from an assisted living home complained of a sensation of incomplete bladder emptying, and was immediately taken to surgery where a transurethral endoscopic laser ablation of the prostate was done upon admission to an acute care hospital. Final diagnosis is BPH.

 

 

 

 

 

 

 

 

Who We Are

 

 

 

 

 

 

 

 

Answer Key

1.) C61 = Malignant neoplasm of the prostate

R34 = Anuria and oliguria

0VT00ZZ = Radical retropubic prostatectomy, open

 

2.) N40.1 = Benign Prostatic Hypertrophy (enlarged prostate) with lower urinary tract symptoms (LUTS)

R39.14 = Feeling of incomplete bladder emptying

0V508ZZ = Destruction of prostate, via natural or artificial opening, endoscopic

 

Problem #1, To Locate C61: Disease Index > Neoplasm Table > 1st column, Malignant Primary > prostate > C61 > verify in Tabular.

To Locate R34: Disease Index > Anuria > R34 > verify in Tabular.

Comments:

  • Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis. The definitive diagnosis should be sequenced before the symptom code.
  • In this case, not every patient who has prostate cancer routinely has the symptoms of anuria. Hence, anuria is coded, and sequenced after C61.

To locate 0VT00ZZ: PCS Index > Prostatectomy > see Resection, Prostate > 0VT0 > locate table 0VT and go across the row to finish building the code and also verify that the 4th character is correct:

Resection of Prostate, Open Approach

PCS Root Ops 54AComments:

  • Resection is defined as “Cutting out or off, without replacement, all of a body part.”
  • The Index gives you a choice of excision or resection. We know the entire prostate was removed because in our diagnostic statement it states that the prostatectomy was radical.

 

Problem #2, To locate N40.1/R39.14: Disease Index > Hypertrophy, hypertrophic > prostate > see Enlargement, enlarged, prostate > with lower urinary tract symptoms (LUTS) > N40.1 > Verify in tabular > Instructional Note: Use additional code for associated symptoms, when specified > incomplete bladder emptying > R39.14 > Verify both codes in Tabular.

Comments, N40.1/R39.14:

  • 1 is a combination code that includes both the enlarged prostate, Benign Prostatic Hypertrophy (BPH) and the lower urinary tract symptom of incomplete bladder emptying.
  • In the Index in red font there is a list of symptoms associated with LUTS. Select the most appropriate symptom.

 

To locate 0V508ZZ: PCS Index > Destruction > Prostate > 0V50 > locate table 0V5 and go across the row to finish building the code. Also verify that the 4th character value is correct:

Destruction of Prostate, Via Natural or Artificial Opening Endoscopic

PCS Root Ops 54B

Comments:

  • In both instances, the prostate was removed/destroyed but the surgical method employed different techniques.
  • In the first example, the prostate was cut out (resected) via an open approach,
  • In the 2nd example the prostate was destroyed via laser ablation.
  • In the PCS Index, the main term ablation sends you to destruction. Think of ablation and destruction as synonymous terms.
  • Destruction is defined as “Physical eradication of all or a portion of a body part by the direct use of energy, force or a destructive agent.” In our example laser was the destructive agent.

 

Directions for Locating the Codes by Going Directly to the Tables

Resection of prostate, open approach

0VT00ZZ

  1. Step #1 is to locate the correct section in your PCS coding book. You know that surgery was performed, so the most logical selection is the Med/Surg section. The majority of procedures are in the Med/Surg section. The first character in the Med/Surg section is always 0.
  2. Step 2: Determine the correct Body System. Since the body part is the prostate, it is only logical that the Body System is the Male Reproductive System. We have identified the first two characters, 0V.
  3. Step 3: Determine the root operation. You know you have to be in a table that starts with 0V. You should also know that the root operations are listed alphabetically. Simply go through the all the tables that start with 0V and look for the root operation, resection. We now have the first three characters, 0VT, which puts us in the correct table. The first 3 character values are always listed for you at the top of the table. It gives the section, Med/Surg; the body system, Male Reproductive; the root operation, Resection.
  4. Step 4: Identify the Body Part to determine the 4th character value. The Body Part, prostate, should relate to the root operation, Resection, because it was the prostate that was resected. We now have 4 character values 0VT0.
  5. Step 5: Determine the Approach. No guesswork regarding the approach, as our diagnostic statement clearly states that the procedure was done via an open approach. We should now have 5 characters, 0VT00.
  6. Step 6: Determine whether or not a device was left in the patient postoperatively. No device was left in place, so assign Z, the placeholder, as the character value. We should now have 6 characters, 0VT00Z.
  7. Step 7: There is no qualifier, so we should now have our code, 0VT00ZZ. Z functions as a placeholder in ICD-10-PCS. In other words, Z is to PCS what X is to ICD-10-CM.

Coding Tidbits Written By: Linda Kobayashi
Edited and Posted By: Andrea Wong

 

For the past few weeks we have given you coding problems that require assignment of both diagnoses and procedures. With respect to the breakdown of diagnostic codes, a new feature, we will only do that for the PDx. This week you will be given a problem to solve from Perinatal Conditions, Chapter 16. Also, directions for locating the codes by using the tables only applies to the principal procedure and it will always be the last item discussed.

 

Problem for this week: A one-day-old 2,200-gram female infant was born prematurely at 34 weeks gestation. She was transferred from another hospital for evaluation of a congenital diaphragmatic hernia. Just before transfer, intubation was necessitated by some respiratory distress. The ventilator support was continued for 3 days. When she was stabilized, the diaphragmatic hernia was repaired via an abdominal approach, and the hernia sac was excised.

 

 

 

 

 

 

 

 

 

 

 

Who We Are

 

 

 

 

 

 

 

 

 

Answer Key:

  1. Q79.0:   Congenital diaphragmatic hernia
  2. P07.18: Other low birth weight newborn, 2000-2499 grams
  3. P07.37: Other preterm newborn, gestational age 34 completed weeks
  4. P22.9:   Respiratory distress of newborn, unspecified
  5. 0WQF0ZZ: Repair abdominal wall, open approach
  6. 5A1945Z: Respiratory ventilation, 24-96 consecutive hours

 

Breakdown of PDx, Congenital Diaphragmatic Hernia:

  • Q79 = Congenital malformations of musculoskeletal system, not elsewhere classified
  • Q79.0 = Congenital diaphragmatic hernia

 

To locate Q79.0: Disease Index > Hernia > diaphragm, diaphragmatic > congenital > Q79.0 >

verify in Tabular.

To Locate P07.18: Disease Index > Low > birthweight > with weight of > 2000-2499 grams > P07.18 > Verify in Tabular.

To Locate P07.37: Disease Index > Preterm > newborn > gestational age > 34 completed weeks > P07.37 > Verify in Tabular.

To Locate P22.9: Disease Index > Distress > respiratory > newborn > P22.9 > Verify in
Tabular.

 

General Comments:

  • No code from category Z38 (liveborn infants) is assigned. The patient wasn’t born in this hospital; rather, she was transferred from another hospital when she was one day old. Codes from category 38 is to be used for the initial birth record only.
  • If you located gestational age (weeks), from the main term, Pregnancy, and then to the sub-term “weeks of gestation,” you would be directed to a code from catetgory Z3A, which is only to be used on the maternal records only. Code Z3A are not to be coded with codes on the liveborn infant record.
  • When both birth weight and gestational age are available, both should be coded with birth weight sequenced before gestational age.
  • Preterm consists of 28 weeks or more but less than 37 completed weeks (196 completed days but less than 259 completed days) of gestation.

 

To Locate 0WQF0ZZ: PCS Index > Herniorrhaphy > see Repair > Anatomical Regions > General > 0WQ > Locate table 0WQ and go across the row to finish building the code:

Repair Abdominal Wall, Open Approach

PCS Root Ops 53A

Comments:

  • Repair is defined as “Restoring, to the extent possible, a body part to its normal anatomic structure and function.”
  • General Anatomical Regions, 2nd character, includes the general body cavities (spaces that contain organs and other structures.) Included in the general regions are the larger surface areas of the body such as the chest wall, abdominal wall, and upper and lower back.
  • One of the larger surface areas of the body is the abdominal wall. Using an open approach, the surgeon was able to access the diaphragmatic hernia, after which the hernia was excised.
  • You may be questioning why Device, the 6th character wasn’t coded. If there is a device, the device character is always specified and indicates the device placed during the procedure.
  • Intubation is not coded because it was performed at the other hospital.

 

To Locate 5A1945Z: PCS Index > Performance > Respiratory > 24-96 Consecutive hours > 5A1945Z

Respiratory Ventilation, 24-96 hours

PCS Root Ops 53B

Comments

  • We were tempted to go to the main term Ventilation but then I remembered that it is faster and easier to go directly to the root operation, Performance.
  • Performance is defined as “Completely taking over a physiological function by extracorporeal means.”
  • The root operation is Performance because the machine has taken over the patient’s cardiac function during the procedure.
  • Note that the 5th character, Approach and Device (Med/Surg section), have been replaced by Duration and Function in the Extracorporeal Assistance and Performance section, respectively.
  • This was an easy one to code because the Index gives you the answer.
  • There are 31 Body Systems under Physiological Systems such as Respiratory, Circulatory, GI System Skin and Breast, et al. The Extracorporeal Assistance and Performance section is included here.

 

Directions for Locating the Codes by Going Directly to the Tables

Herniorrhaphy of Abdominal wall

0WQF0ZZ

 

  1. Step #1 is to locate the correct section in your PCS coding book. The majority of procedures are in the Med/Surg section. The first character in the Med/Surg section is always 0.
  2. Step 2: Determine the correct Body System – General Anatomical Regions. Since you are dealing with Anatomical Regions and since you know that the abdominal wall is part of Anatomical Regions, it should be easy to determine the body system. Thus far, we have identified the first two characters, 0W.
  3. Step 3: Determine the root operation. You know you have to be in a table that starts with 0W. From this point I would look for the root operation, Repair, by scanning through the tables. The root operations are listed alphabetically, so it shouldn’t be hard to find the correct one. We now have the first three characters, 0WQ, which puts us in the correct table. The first 3 character values are always listed for you at the top of the table. It gives the section, Med/Surg; the body system, Anatomical Regions, General; the root operation, Repair.
  4. Step 4: Identify the Body Part to determine the 4th character value. The Body Part, Abdominal Wall, should relate to the root operation, Repair, because it was the diaphragmatic hernia that was repaired. We now have 4 character values 0WQF.
  5. Step 5: Determine the Approach. No guesswork regarding the approach, as our diagnostic statement clearly states that the procedure was done via an abdominal approach, which is an open approach. We should now have 5 characters, 0WQF0.
  6. Step 6: Determine whether or not a device was left in the patient postoperatively. No device was left in place, so assign Z, the placeholder, as the character value. We should now have 6 characters, 0WQF0Z.
  7. Step 7: There is no qualifier, so we should now have our code, 0WQF0ZZ. Z functions as a placeholder in ICD-10-PCS. In other words, Z is to PCS what X is to ICD-10-CM.

Coding Tidbits Written By: Linda Kobayashi
Edited and Posted By: Andrea Wong

 

We will continue to give you problems that include both diagnoses and procedures. This week we are focusing on a problem from the Diseases of the Musculoskeletal System and Connective Tissue, Chapter 13.

 

Problem for the week: After falling from a ladder while working on his house, the patient was brought to the ER where he was admitted. He sustained contusions of the scalp and face and an open type I intertrochanteric fracture of the right femur. The fracture site was excisionally debrided, and an open reduction with internal fixation was carried out. Don’t assign E codes except for the external cause of the injury.

 

 

 

 

 

 

 

Who We Are

 

 

 

 

 

 

 

 

Answer Key:

  • S72.141B: Displaced intertrochanteric fracture of the right femur, initial encounter, for open fracture type I or II
  • S00.03xA: Contusion of scalp
  • S00.83xA: Contusion of other part of head
  • W11.xxxA: Fall from ladder
  • 0QS604Z: Open reduction with internal fixation (reposition right upper femur)
  • 0QB60ZZ: Debridement (root operation “Excision”)

 

Breakdown of S72.141B

S72 = Fracture of Femur

S72.1 = Pertrochanteric fracture

S72.14 = Intertrochanteric fracture of femur

S72.141B = Displaced intertrochanteric fracture of right femur; initial encounter, for open fracture type I or II

 

To locate S00.03xA: Alphabetic Index > Contusion > scalp > S00.03 > Tabular to obtain remaining digits (all ICD-10-CM codes are 7 digits long) > 7th digit required > the next 6th character is x, placeholder in ICD-10-CM > S00.03x > S00.03xA (A is initial encounter.)

To Locate S00.83xA: Alpha Index > Contusion > face NEC > S00.83 > Go to the Tabular to assign remaining digits so you come out with a total of 7 digits > S00.83x > (x is the placeholder for ICD-10-CM, just as Z is the placeholder for procedures) > S00.83xA (A is for initial encounter.)

To Locate W11.xxxA: Index to External Causes > Fall, falling > from, off, out of > ladder > W11 > Tabular: 3rd, 4th, and 5th character, placeholder is x > W11.xxx > 7th character is the A-initial encounter > W11.xxxA.

To Locate 0QS604Z > PCS Index > Reposition > Femur > Upper > Right > 0QS6 > locate table 0QS and go across the row to finish building the code, remembering to verify the 4th character:

 

Reposition Right Upper Femur with Internal Fixation Device, Open Approach

PCS Root Ops 52A

Comments:

  • PCS divides the bones into upper and lower. Anything above the diaphragm is considered an upper bone and anything below the diaphragm would be considered a lower bone.
  • There are some new terms in ICD-10-PCS and this is a good example. Reposition replaces Reduction.
  • Reposition is defined as “Moving to another location or other suitable location all or a portion of a body part.
  • An intertrochanteric fracture involves the proximal femur, which consists of the femoral head, the femoral neck, and the trochanteric region (including the greater and lesser trochanters.
  • The bone was fixated with an internal fixation device. A device is used only to specify devices that remain after the procedure is completed

 

To Locate 0QB60ZZ: PCS Index > Debridement > Excisional > see Excision > Femur > Upper > Right > 0QB6 > locate table 0QB and go across the row to finish building the code, and remember to verify the 4th character:

Excision of Right Upper Femur, Open Approach

PCS Root Ops 52B

Comments:

  • Before setting the bone, some debridement of the femur was required.
  • Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue.
  • Excision is defined as ‘Cutting out or off, without replacement, a portion of a body part.” Please note that the main difference between these 2 root operations is that in Replacement, it always involves a device. In an excision procedure, which is the case in our scenario, the dead or damaged tissue is not replaced.
  • Upper bones versus lower bones applies to this part of the problem, e.g., above/below the diaphragm.
  • If you do an alpha search for all root operations in the 0QB tables, you will see that debridement is not included.

Directions for Locating the Codes by Going Directly to the Tables

REPOSITION OF FEMUR WITH ORIF

0QS604Z

  1. Step #1 is to locate the correct section in your PCS coding book. The majority of procedures are in the Med/Surg section. The first character in the Med/Surg section is always 0.
  2. Step 2: Determine the correct Body System – lower bones. Since you are dealing with the Musculoskeletal System (MS) and since you know that the femur is part of the MS System, it should be easy to determine the body system. PCS divides the bones into upper and lower. Thus far, we have identified the first two characters, 0Q.
  3. Step 3: Determine the root operation. You know you have to be in a table that starts with 0Q. The root operations are listed alphabetically, so it shouldn’t be hard to find the correct root operation. Our root operation is Reposition. We now have the first three characters, 0QS, which puts us in the correct table. The first 3 character values are always listed for you at the top of the table. It gives the section, Med/Surg; the body system, Lower Bones; the root operation, Reposition.
  4. Step 4: Identify the Body Part to determine the 4th character value. The Body Part, upper right femur, should relate to the root operation, Reposition, because it was the femur that was repositioned. We now have 4 character values 0QS6.
  5. Step 5: Determine the Approach. No guesswork regarding the approach, as our diagnostic statement clearly states that the procedure was done via an open approach. We should now have 5 characters, 0QS60.
  6. Step 6: Determine whether or not a device was left in the patient postoperatively. This procedure an ORIF (open “reposition” with internal fixation) was carried out. This clearly indicates that a device was left in place. We should now have 6 characters, 0QS604.
  7. Step 7: There is no qualifier, so we now have our code of 0QS604Z. Z functions as a placeholder in ICD-10-PCS.

Coding Tidbits Written By: Linda Kobayashi
Edited and Posted By: Andrea Wong

 

For the past few weeks we have given you coding problems that require assignment of both diagnoses and procedures. With respect to the breakdown of diagnostic codes, a new feature, we will only do that for the PDx. This week you will be given a problem to solve from the Digestive System, Chapter 11. As a reminder, directions for coding directly from the tables will always be the last item and it only gives directions for the principal procedure.

 

Problem for the week: A patient with a 20-year history of severe complicated ulcerative colitis was admitted for surgical intervention. A total abdominal colectomy with ileostomy was performed via open approach.

 

 

 

 

 

 

 

 

Who We Are

 

 

 

 

 

 

 

 

 

 

Answer Key:

K51.919: Ulcerative colitis, unspecified with unspecified complications

0DTE0ZZ: Resection of large intestine, open approach

0D1B0Z4: Bypass ileum to cutaneous, open approach

 

Breakdown of K51.919:

K51 = Ulcerative colitis

K51.9 = Ulcerative colitis, unspecified

K51.91 = Ulcerative colitis, unspecified, with complications

K51.919 = Ulcerative colitis, unspecified with other complication

 

To Locate K51.919: Colitis > ulcerative > with > complications > K51.919 > verify in

Tabular.

To Locate 0TDE0ZZ: Resection > Intestine > Large > 0DTE > locate table 0DT and go across the row to finish the code, verifying the 4th character:

Resection of Large Intestine, Open Approach

PCS Root Ops 51A

Comments:

  • Resection versus excision: Resection is cutting out or off without replacement, all of a body part. The entire large intestine was removed.
  • Excision is cutting out of or off, without replacement a portion of a body part. If only a portion of the large intestine had been removed, you would code it to excision.
  • Å colectomy neither cures nor eliminates Ulcerative Colitis/Crohn’s disease; instead it removes the entire diseased large intestine.
  • Ileostomy is a surgical opening (stoma) constructed by bringing the end or loop of small intestine (the ileum) out onto the surface of the skin and to the surgical procedure which creates this opening. Intestinal waste passes out of the ileostomy and is collected in an artificial external pouching system, which is adhered to the skin.

 

To Locate 0D1B0Z4: PCS Index > Bypass > Ileum > 0D1B > locate table 0D1 and go across the row to finish building the code, and also verify that the 4th character of Ileum is correct:

Bypass Ileum to Cutaneous, Open Approach

PCS Root Ops 51B

Comments:

  • Bypass is defined as “Altering the route of passage of the contents of a tubular body part.”
  • There are three methods and more specifically, they are:
    • Rerouting contents from one area of a body part to a downstream area in the normal route;
    • Rerouting the contents to a similar route and body part, or to an abnormal route and a dissimilar body part. Includes one or more anastomoses, with or without the use of a device.
    • Guideline B3.6a indicates that the “fourth character body part specifies the body part bypassed from, and the qualifier specifies the body part bypassed to.” In this scenario, the ileum is redirected to the external cutaneous part of the body. In other words, the 4th character, ileum, is the origin of the bypass, and the 7th character, cutaneous, is the destination of the bypass.

 

 

Directions for Locating the Codes by Going Directly to the Tables

0DTE0ZZ

  1. Step #1 is to locate the correct section in your PCS coding book. The majority of procedures are in the Med/Surg section. The first character in the Med/Surg section is always 0.
  2. Step 2: Determine the correct Body System – Gastrointestinal System. Since you are dealing with the large intestine and since you know that the large intestine is part of the GI System, it should be easy to make this determination. Thus far, we have identified the first two characters, 0D.
  3. Step 3: Determine the root operation. You know you have to be in a table that starts with 0D. From this point I would look for the root operation, Resection, by scanning through the tables. The root operations are listed alphabetically, so it shouldn’t be hard to find the correct root operation. Our root operation is Resection. We now have the first three characters, 0DT, which puts us in the correct table. The first 3 character values are always listed for you at the top of the table. It gives the section, Med/Surg; the body system, Gastrointestinal System; the root operation, Resection.
  4. Step 4: Identify the Body Part to determine the 4th character value. The Body Part, large intestine, should relate to the root operation, Resection. We now have 4 character values 0DTE.
  5. Step 5: Determine the Approach. No guesswork regarding the approach, as our diagnostic statement clearly states that the procedure was done via an open approach. We should now have 5 characters, 0DTE0.
  6. Step 6: Determine whether or not a device was left in the patient postoperatively. In the case of our procedure, there was no devices left after surgery, so we should now have 6 characters, 0DTE0Z.
  7. Step 7: There is no qualifier, so we now have our code of 0DTE0ZZ. Z functions as a placeholder in ICD-10-PCS.

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