ICD-10-PCS, Root Operations – Part 20, Procedures: Question

ICD-10-PCS, Root Operations – Part 20, Procedures: Question

Last week we discussed guidelines for biopsies. This week we will focus on the guidelines for Inspection procedures. Inspection is defined as 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. We will go over the guidelines first followed by some coding procedures that will give you an opportunity to put these guidelines into practice.

 

INSPECTION GUIDELINES

Guideline B3.11a:  Inspection of a body part(s) performed in order to achieve the objective of a procedure is not coded separately.

Example - Fiberoptic bronchoscopy performed for irrigation of bronchus, only the irrigation procedure is coded.

 

INSPECTION OF TUBULAR AND NON-TUBULAR BODY PARTS

Guideline B3.11b:  If multiple tubular body parts are inspected, (e.g., esophagus, blood vessel, ureter), the most distal body part inspected is coded. If multiple non-tubular body parts in a region are inspected, the body part that specifies the entire area inspected is coded.

Examples - Cystoureteroscopy with inspection of bladder and ureters is coded to the ureter body part value.
Exploratory laparotomy with inspection of abdominal contents is coded to the peritoneal cavity body part value.

 

INSPECTION AND OTHER PROCEDURES PERFORMED ON SAME BODY PART

Guideline B3.11c:  When both an Inspection procedure and another procedure are performed on the same body part during the same episode, if the Inspection procedure is performed using a different approach than the other procedure, the Inspection procedure is coded separately.

Example - ‘Endoscopic’ Inspection of the duodenum, (e.g, EGD), is coded separately when ‘open’.
Excision of the duodenum is performed during the same procedural episode.

 

 

PROCEDURES FOR THIS WEEK:

  1. Fiberoptic bronchoscopy performed for irrigation of bronchus.
  2. Cystoureteroscopy with inspection of bladder and ureters.
  3. EGD followed by open excision of the duodenum.

For the past few weeks we have worked on root operations that take out some or all of a body part. We are going to continue our discussion, focusing on excision and resection procedures.

Coding problems for this week:

  1. Laparoscopic excision of right ovarian cyst followed by a total oophorectomy.
  2. Right breast lumpectomy followed by total mastectomy, open approach.

 

 

 

 

 

Who We Are

 

 

 

 

 

 

Answer Key:

  1. 0UB04ZX; 0UT04ZZ
  2. 0HBT0ZX; 0HBT0ZX

 

Problem #1, Laparoscopic excision of right ovarian cyst, diagnostic.
To Locate:  PCS Index > Excision > Ovary > Right > 0UB0 > Locate table 0UB and go across the row to finish building the code:

Excision of right ovary, percutaneous endoscopic approach

PCS root 19 a 

Problem #1, Part 2 cont’d, Right Oophorectomy
To Locate:  PCS Index > Resection > Ovary > Right > 0UT0 > locate 0UT and go across the row to finish building the code:

Resection of right ovary, percutaneous endoscopic approach

PCS root 19 b

Definition, Excision vs. Resection:  Excision is defined as cutting out or off, without replacement, a portion of a body part, whereas Resection is defined as cutting out or off, without replacement, all of a body part

  • The qualifier DIAGNOSTIC is used to identify excision procedures that are biopsies.
  • New Guidelines, B3.4a, B3.4b
  • GL B3.4a, Biopsy Procedure:  Biopsy procedures are coded using the root operations Excision, Extraction, or Drainage and the qualifier Diagnostic. For example, lymph node sampling, partial nephrectomy, liver biopsy by excision of tissue….
  • GLB3.4b, Biopsy followed by more definitive procedure:  If a diagnostic Excision, Extraction, or Drainage procedure (biopsy) is followed by a more definitive procedure, such as Destruction, Excision or Resection at the same procedure site, BOTH the biopsy AND the more definitive treatment are coded. For example, a biopsy of the breast followed by a partial mastectomy at the same procedure site, both the biopsy and the partial mastectomy procedure are coded.
  • Approach:  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. A puncture is made in the abdomen followed by insertion of the scope. This is considered a laparoscopy.

 

Problem #2, Right breast lumpectomy followed by total mastectomy.
To Locate:  PCS Index > Lumpectomy > see Excision > Breast > Right > 0HBT > locate table 0HB and go across the row to finish building the code:

Excision of right breast, open approach, diagnostic

PCS root 19 c

Problem #2, Part 2 cont’d, Mastectomy
To Locate:  PCS Index > Mastectomy > see Resection, Skin and Breast > Breast > Right > 0HTT0ZZ> Even though the Index gives you the code, you should still refer to table 0HT and go across the row to verify that the code is correct:

Resection of right breast, open approach

PCS root 19 d

 

NOTE:  An ‘excision’ is coded when only a part of the organ is removed and there is a portion left behind.

 

Previously we reviewed root operations that take out some or all of a body part, including excision, resection, detachment, destruction and extraction. You matched root operations with the appropriate procedure. This week you are going to code some of those procedures.

 

Coding questions for this week:

  1. Rectal polyp fulguration.
  2. Suction D&C via natural opening endoscopic.
  3. Below knee amputation, right leg, “high.”

 

 

 

 

Who We Are

 

 

 

 

 

 

 

Answer Key:

  1. 0D5P4ZZ
  2. 0UDB7ZZ
  3. 0Y6H0Z1

Problem #1, Fulguration of rectal polyp via natural opening endoscopic

To Locate:  PCS Index > Fulguration > see Destruction > 0D5P > Go to table 0D5 and then go across the row to finish building the code:

Destruction of rectum, via natural or artificial opening endoscopic

Root PCS - 18 a

  • Fulguration: Physical eradication of all or a portion of a body part by the direct use of energy, force or a destructive agent.
  • Body Part:  When the site of a procedure is around or surrounding a body part, the procedure is coded to the body part named. The polyp, not the rectum, was destroyed. It’s a little tricky because the wording makes it sound as if the rectum, not the polyp, was destroyed.
  • Approach: Entry of instrumentation through a natural or artificial external opening to reach and ‘visualize’ the site of the procedure defines the approach, Via Natural or Artificial Opening Endoscopic. The scope was inserted through a natural opening, the anus, and the site of the procedure was the rectum. Other examples utilizing this approach include EGD, sigmoidoscopy, and urethroscopy.

 

Problem #2, Suction D&C (non-ob) via natural opening

To Locate:  PCS Index > Suction curettage (D&C) > see Extraction, Endometrium > 0UDB

> Find table 0UD and go across the row to finish building the code:

Extraction of endometrium, via natural or artificial opening

Root PCS 18 b

  • Extraction: Pulling or stripping out or off all or a portion of a body part by the use of force. Two other examples of extraction, for example, include forceps removal of teeth and vein stripping.
  • Approach: Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure defines the approach, Via Natural or Artificial Opening. No visualization instrument is utilized (e.g., scope.) Examples of procedures utilizing this same approach include transurethral prostatectomy, endotracheal intubation, trans-vaginal cervical cerclage.

 

Problem #3, Below-knee amputation, right leg, at the proximal tibia/fibula

To Locate:  PCS Index > Amputation > see Detachment > Leg > Lower > Right > 0Y6C0Z > Even though the index gives you all but the 7th character, you should still verify the code by locating table 0Y6 and going across the row to validate characters 4, 5, and 6, plus assign the 7th character:

Detachment at right lower leg, high, open approach

Root PCS 18 c

  • Detachment: Cutting off all or a part of the upper or lower extremities.
  • Body Part: Amputation is performed by disarticulation or cutting through the bone. The body part value is the site of the detachment; the right leg in our scenario.
  • Qualifier:  A qualifier, if applicable, is assigned to further specify the level at which the extremity was detached. The disarticulation took place at the proximal portion of the shaft of the tibia/fibula, hence a qualifier of 1 is assigned to the 7th character.
  • Note:  “Detachment” procedures are found only in body systems “X” (“Anatomical Regions, Upper Extremities”) and “Y” (“Anatomical Regions, Lower Extremities”) because amputations are performed on the extremities, across overlapping body layers (e.g., skin, muscle, bone), and therefore cannot be coded to a specific musculoskeletal body system, such as bones or joints.
  • ICD-10-PCS has codes for 3 different types of extremity amputations:
  • High:  Amputation at the proximal portion of the shaft of the tibia/fibula or radius/ulna
  • Mid:  Amputation at the middle portion of the shaft of the tibia/fibula or radius/ulna
  • Low: Amputation at the distal portion of the shaft of the tibia/fibula or radius/ulna

This week we are reviewing root operations that “Take out some or all of a body part.” There have been previous discussions about these root operations. However, rather than throwing something new at you each week, a re-review may be helpful. The root operation, specified by the 3rd character, identifies the objective of the procedure.

PCS Root Op 17 table

Match the following root operations with the appropriate procedure(s): 

  1. Excision:  _____________                       
  2. Resection:  ____________                        
  3. Detachment:  __________                       
  4. Destruction:  __________                       
  5. Extraction:  ___________

 

A. Rectal polyp fulguration ovarian cyst

B. Laparoscopic excision of right

C. Suction D&C

D. Below knee amputation, right leg

E. Diagnostic dilatation and curettage

F. Laparoscopic right oophorectomy

G. Breast lumpectomy, right breast

H. Total mastectomy, left breast

I. Fulguration of endometrium via natural opening

 

 

 

 

Who We Are

 

 

 

 

Answer Key:

  1. B, G
  2. F, H
  3. D
  4. A, I
  5. C, E

 

Don’t worry about the ICD-10-PCS codes. The purpose of this exercise is to reinforce your understanding of the various procedures that may apply to the root operations. Next week I will review the codes and how to locate them.

 

Question for this week:           

  1. Left percutaneous cardiac catheterization.
  2. Swan-ganz catheter pulmonary artery

 

 

 

 

Who We Are

 

 

 

 

 

 

ANSWER KEY

  1. 4A023N7
  2. 4A133B3

ANSWER KEY RATIONALE

  1. Problem #1, Left percutaneous cardiac catheterization

To locate:  PCS Index > Catheterization > Heart > see Measurement, Cardiac > 4A02 >

Locate table 4A0 and go across the row to finish building the code:

Measurement of cardiac sampling and pressure, left heart, percutaneous approach

Section Body System Root Operation Body Part Approach Function Qualifier

4

A

0

2

3

N

7

Measurement and Monitoring Physiological Systems Measurement Cardiac Percutaneous Sampling and Pressure Left Heart
  • Measurement and Monitoring (M&M). Measurement determines the level of a physiological/physical function at a given point in time, whereas Monitoring determines the level of function repetitively over a period of time.
  • Function:  The 7 characters that make up a PCS code in this section are the same as those in the Med/Surg section with the exception of the 6th character, Function/Device. Character 6 in the M&M section represents the physiological/physical function being measured or monitored, such as conductivity, rhythm, and pulse. Devices being monitored include pacemakers, defibrillators, and stimulators.
  • Qualifier:  The 7th character designates more specific information about the function that is measured or monitored, such as whether it was performed intraoperatively, involved the Right Heart or Left Heart, etc. Commonly performed procedures in this section include EKGs, EEGs, and cardiac catheterizations.
  • Percutaneous Approach:  The catheter is inserted by puncturing an artery or vein, usually in the groin. The approach is considered percutaneous when the targeted site is done via puncture.
  1. Problem #2, Swan-Ganz catheter pulmonary artery

To Locate:  PCS Index > Monitoring > Arterial > Pressure > Coronary > 4A13 > Locate table 4A1 and go across the row to complete the code:

Monitoring of arterial pressure, pulmonary, percutaneous approach

Section Body System Root Operation Body Part Approach Function/Device Qualifier

4

A

1

3

3

B

3

Measurement and Monitoring Physiological Systems Monitoring Arterial Percutaneous Pressure Pulmonary
  • Swan-Ganz catheterization is the passing of the catheter into the right side of the heart and the arteries leading to the lungs to monitor the heart’s function and blood flow.
  • Its purpose is diagnostic. The pulmonary artery catheter allows direct, simultaneous measurement of pressures in the right atrium, right ventricle, pulmonary artery and the filling pressure (“wedge” pressure) of the left atrium.
  • Body System:  The Physiological Systems and Regions include body parts for arteries and veins, the products of conception, and the major body systems.
  • Function:  The function is to monitor the pressure in atrium/R. ventricle.

Qualifier:   The Qualifier, Pulmonary, gives more specific information about the procedure. This is a pulmonary artery catheterization.

Questions for this week:

  1. Cystoscopic dilation of right ureteral stricture, with stent placement
  2. PTCA of 3 coronary arteries, RCA, LAD and circumflex. The RCA and LAD were done with drug-eluting stents, and the left circumflex without a stent.

 

 

 

 

Who We Are

 

 

 

 

 

 

ANSWER KEY

  1. 0T768DZ
  2. 027134Z, 02703ZZ

ANSWER KEY RATIONALE

  1. Problem #1, Cystoscopic dilation R. ureteral stricture, with stent placement

To Locate:  PCS Index > Dilation > Ureter > Right > 0T76 > Locate table 0T7 and go across the row to complete the code:

Cystoscopic dilation right ureter with intraluminal device, via natural or artificial opening Endoscopic

Part 1

  • Dilation procedures expand the diameter of a tubular body part, most often a blood vessel. A dilation root operation involves making the orifice or lumen of the tube larger rather than smaller. Anal sphincter dilation and ERCP with balloon dilation of bile duct are two examples of other types of dilation.
  • Approach:  Via Natural or Artificial Opening Endoscopic is defined as “Entry of instrumentation through a natural or artificial external opening to reach and ‘visualize’ the site of the procedure.” The scope is inserted through the urethra, a natural opening. Stent placement required the use of a scope, the cystoscope. Some other examples of this approach include EGD and sigmoidoscopy.
  • Device: An intraluminal device is a device within the lumen of any tubular structure or organ. The lumen is the cavity or channel within a tube or tubular organ. In addition to our scenario of ureteral stent placement, some other examples include bare metal coils, esophageal stents and drug-eluting and non drug-eluting stents.

 

 

Problem #2, PTCA of 3 coronary arteries, RCA and LAD with drug eluting stents, left circumflex without stent

NOTE:  When the identical procedure is not performed on all coronary artery sites (such as whether a device is used), the procedures must be coded separately. The 2 sites with drug-eluting stent placement may be coded as one Body Part value (Coronary Artery, Two Sites), reportable with one code, but the artery that did not have stent placement must be coded separately.

To Locate PTCA, 2 coronary arteries, with stent placement:  PCS Index > Dilation > Artery > Coronary > 2 sites > 0271 > Locate table 027 and go across the row to complete the code:

Dilation of coronary artery, two sites with drug-eluting intraluminal device, percutaneous approach

Part 2

  • Drug-Eluting Stents:  The drug is slowly released into the vessel wall tissue over a period of 30 to 45 days to prevent the build-up of scar tissue that can narrow the reopened artery.
  • Percutaneous Approach:  A blood vessel is punctured in the groin area. A stent is threaded through the blood vessel to the targeted site. “Puncture” meets the definition of Percutaneous approach:  “Entry by puncture or minor incision….” Also see guideline B.54:
  • Guideline B.54: Procedures performed percutaneously via a device placed for the procedure are coded to the approach Percutaneous.
  • Device:  Devices that remain in the body at the conclusion of the procedure should be coded.
  • We still have to account for the circumflex artery. The angioplasty performed on the left circumflex artery, one of the major coronary arteries, was done without stent placement.

 

 

Problem #2 cont’d, Dilation of one coronary artery, percutaneous approach

To Locate:  Dilation > Artery > Coronary > one site > 0270 > Locate table 027 and go across the row to finish building the code:

Part 3

 

Problems for this week – Code the following:

  1. Laparoscopic cholecystectomy converted to an open and complete cholecystectomy.
  2. Liposuction, right upper leg.

 

 

 

Who We Are

 

 

 

 

Answer Key Rationale

 

Problem #1,  Laparoscopic cholecystectomy converted to open, complete

To Locate:  PCS Index > Cholecystectomy > see Resection, Gallbladder > 0FT4 > Locate table 0FT and go across the row to finish building the code:

Resection of gallbladder, open approach

PCS, Root Ops - A

  • Resection:  The PCS Index gives you two choices: Resection or Excision. We went with Resection because the entire gallbladder was removed. In resection procedures, the entire organ is removed, whereas in excision procedures, only part of an organ is removed. Resection is the root operation because the entire gallbladder was removed. Resection is defined as cutting out or off, without replacement, all of a body part
  • Open Approach:  Even though the procedure started out laparoscopically, it was converted to an open procedure. Open is defined as cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure.
  • Converted to Open:  A laparoscopic procedure was attempted but was converted to an open procedure. Guideline B3.2.d:  During the same operative episode, multiple procedures are coded if the intended root operation is attempted using one approach, but is converted to a different approach. Laparoscopic cholecystectomy converted to an open cholecystectomy is coded as percutaneous endoscopic Inspection and open Resection. Therefore, codes that capture both of these approaches are coded.

 

Problem #1 cont’d, to account for inspection of gallbladder

To Locate:  PCS Index > Inspection > Gallbladder > 0FJ4 > Locate table 0FJ and go across the row to finish building the code:

Inspection of gallbladder, percutaneous endoscopic approach

PCS, Root Ops - B

  • Inspection is defined as visually or manually exploring a body part. The gallbladder was inspected before the procedure was converted to an open approach. Don’t let this confuse you with the rule that procedures performed using an open approach with percutaneous endoscopic assistance are coded only to approach value ’0′ Open. We still have to account for the inspection as well as follow guideline B3.2.d.
  • The approach is considered Percutaneous Endoscopic because the procedure started out laparoscopically.

 

Problem #2, Liposuction for medical purposes, right upper leg

To Locate:  PCS Index > Extraction > Subcutaneous Tissue and Fascia > Upper Leg > Right > 0JDL > Locate table 0JD and go across the row to finish building the code: 

Extraction of right upper leg subcutaneous tissue and fascia, percutaneous approach

PCS, Root Ops - C

  • If you can’t locate a main term for liposuction, where do you go? This is when it helps to familiarize yourself with some of the new terminology found in ICD-10. Extraction is defined as pulling or stripping out or off all or a portion of a body part by the use of force.
  • Percutaneous Approach:  The Percutaneous approach is inherent in the liposuction technique. To select the body system and body part, Subcutaneous Tissue and Fascia is selected because this procedure occurs under the skin into the subcutaneous tissue and fat.
  • Note that if liposuction is done for medical purposes, it is considered Extraction. If it is done for cosmetic purposes, it is considered Alteration.

Answer Key

  1. 0U5B4ZZ, 0U574ZZ
  2. 0H5GXZD, 0H5FXZZ

 

Answer Key Rationale

Problem #1, To Locate:  PCS Index > Ablation see Destruction > Endometrium > 0U5B > locate 0U5 and go across the row to finish building the code:

Destruction of Endometrium, Percutaneous Endoscopoic Approach

PCS Part 13, A

 

The approach is Percutaneous Endoscopic because a laparoscope was used. If the procedure had been done through the vagina, Via Natural or Artificial Opening, would have been used.
Some examples of destruction other than endometrium/tubes are:

- Cautery of varicose vein

- Cryosurgery

- Fulguration of a rectal polyp

- Laser ablation of arrhythmogenic focus AV node

- Pleurodesis, scarification (mechanical abrasion)

- Transurethral needle ablation of prostate (TUNA)

  •  In addition to destruction of the endometrium, the fallopian tubes were also destroyed, so we’re not finished with this problem yet.
  • Guideline B3.2.a:  Multiple procedures are coded if the same root operation is performed on different body parts as defined by distinct values of the body part character.

 

Destruction of Bilateral Fallopian Tubes, Percutaneous Endoscopic Approach

PCS Part 13, B

 

Problem #2, Cryotherapy of 3 warts on left hand and 1 wart on right hand

To Locate:  PCS Index > Cryotherapy > see Destruction > Skin > Hand > Left > 0H5GXZ > Locate table 0H5 to assign the 7th character:

 

Destruction of Left Hand Skin, Multiple, External Approach

PCS Part 13, C

  • The approach is External, assigned to procedures performed directly on the skin.
  • See above-referenced problem for discussion on Destruction.
  • The 7th character qualifier is Multiple because 3 warts were removed. Let’s move on to the left hand:

 

Problem #2 cont’d

To Locate: PCS Index > Cryotherapy > see Destruction > Skin > Hand > Right > 0H5FXZ > Locate table 0H5 to assign the 7th character:

 

Destruction of Right Hand Skin External Approach

PCS Part 13, D

  • Because only 1 wart on the right hand was destroyed, the 7th character is Z, No Qualifier. If more than one wart had been destroyed, as was the case with the left hand, then the Multiple Qualifier would have been assigned.

Because procedure coding is more of a challenge than diagnostic coding, we will continue to stay focused in this area. You will be coding a variety of procedures. The problems for this week focus on destruction. Destruction, the root operation in ICD-10-PCS, 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.” The problems for this week are as follows:

  1. Laparoscopy with ablation of endometriosis, endometrium, and bilateral fallopian tubes.
  2. Cryotherapy of 3 warts on left hand and 1 wart on right hand.

Answer Key:

  1. 0HBCXZZ, 0HBFXZZ
  2. 0TB43ZX
  3. 0DBN8ZZ
  4. 0DTM0ZZ

Problem #1, Excision of left upper arm skin, external approach

To Locate:  PCS Index > Excision > Skin > Upper Arm > Left > 0HBCXZ > Go to table 0HB to verify the code listed in the Index and to assign the 7th character:

Excision malignant melanoma from skin left upper arm and right hand

PCS Part 12 - A

To Locate:  PCS Index > Excision > Skin > Hand > Right > 0HBFXZ > Go to table 0HB to verify the code listed in the Index and to assign the 7th character: 

Problem #1 cont’d, Excision of skin of right hand

PCS Part 12 - B

NOTE:  This is NOT diagnostic because the diagnosis of malignant melanoma was established.

 

Problem #2, Percutaneous needle core biopsy (diagnostic) of left kidney pelvis:

To Locate:  PCS Index > Biopsy > see Excision with qualifier Diagnostic > Excision > Kidney Pelvis > Left > 0TB4 > Locate table 0TB and go across the row to complete the code:

Excision of Left Kidney Pelvis, Percutaneous Approach, Diagnostic

PCS Part 12 - C

Just a reminder that the 7th character of X, Diagnostic, tells us that this is a biopsy, not excision of the entire kidney pelvis. Also, there is no documentation that this is a drainage procedure.

 

Problem #3, Sigmoidoscopy with sigmoid polypectomy:

To Locate:  PCS Index > Polypectomy, gastrointestinal, see Excision, Gastrointestinal System > 0DB > Locate table 0DB and go across the row to complete the code:  Don’t worry if you don’t find a listing for the GI System under the main term excision; simply look for an alternative subterm > Colon > Sigmoid > 0DBN > locate table 0DB and go across the row to finish building the code:

PCS Part 12 - D

Approach:  The scope is inserted through a natural opening, the anus, and the procedure title, sigmoidoscopy, tells us that an endoscope was used.

Guideline B3.11a:  Inspection of a body part(s) performed in order to achieve the objective of a procedure is not coded separately. Therefore, the sigmoidoscopy is not coded.

 

Problem #4, Open resection of descending colon:

To Locate:  PCS Index > Resection > Colon > Descending > 0DTM > Locate table 0DT and go across the row to finish building the code:

Resection of Descending Colon, Open Approach

PCS Part 12 - E

The entire descending colon was resected. If a portion had been removed, Excision would be coded.

From the Blog

ICD-10-PCS, Root Operations – Part 20, Procedures: Question

Last week we discussed guidelines for biopsies. This week we will focus on the guidelines for Inspecread more