Problem #1, Needle Biopsy Right Lobe of Liver
- Explanation: The qualifier DIAGNOSTIC is used to identify excision procedures that are biopsies.
- Percutaneous Approach: Entry by puncture or minor incision, or instrumentation through the skin or mucous membrane and/or any other body layers necessary to reach the site of the procedure. Some other examples include: Percutaneous Drainage of Abscess, Thoracentesis, Transvenous Insertion of Pacemaker Lead AND Injection.
Problem #2, Endotracheal Intubation
To Locate: Intubation > Airway > see insertion of device in, Trachea > 0BH1 > locate table 0BH and go across the row to finish building the code:
- Definition: Putting in a nonbiological device that monitors, assists, performs or prevents a physiological function, but DOES NOT physically take the place of a body part.
- Examples: Brachytherapy seed placement, Implantation of VAD, Insertion of a central venous catheter, Placement of cardiac pacemaker, Placement of an intrathecal infusion pump for pain management
Problem #3, Manual rupture knee joint adhesions
To Locate: PCS Index > Rupture > Adhesions > see Release > Joint > Knee > Left > 0SND > go to table 0SSN and go across the row to complete the code:
- Definition: Freeing a body part from an abnormal physical constraint by cutting or by use of force.
- Explanation: Some of the restraining tissue may be taken out, but none of the body part is taken out.
- Examples: Adhesiolysis, Carpal tunnel release, Release of median nerve, Relaxation of scar contracture, Frenulotomy, Achilles tendon release
RELEASE GUIDELINE B3.13: In the root operation Release, the body part value coded is the body part being freed and not the tissue being manipulated or cut to free the body part.
CODING NOTE: The ‘body part value’ assigned is the structure released and NOT the structure cut to obtain the release.
- Examples: – The transverse carpal ligament was cut to release the median nerve and not for its own sake – Lysis of intestinal adhesions is coded to the specific intestine body part value with root operation Release
Problem #4, Resection of tonsils, external approach
To Locate: PCS Index > Tonsils > 0CTP > go to table 0CT to complete the code:
Resection of tonsils, external approach
- Definition: Procedures performed directly on the skin or mucuous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane.
- Explanation: Includes procedures on structures that are visible without the aid of any instrumentation to reach the site.
- Examples: Resection of tonsils, Closed reduction of fracture, Local skin excision, Debridement of skin, Extubation, endotracheal tube, Removal of nasogastric drainage tube
Problem #5, Local excision of skin lesion of neck
To Locate: PCS Index > Excision > Skin > Neck > 0HB4XZ > go to table 0HB to 1) verify characters 4-6 and 2) Assign 7th character:
- Definition: Cutting out or off, without replacement, a portion of a body part
- Examples: Partial nephrectomy, Liver biopsy by excision of tissue, Polypectomy, Wedge ostectomy, Pulmonary segmentectomy, Breast lumpectomy
Problem #6 Reattachment severed right ear
To Locate: PCS Index > Reattachment > Ear > Right > 09M0XZZ > locate table 09M and go across the row to verify the code:
- Definition: Putting back in or on all or a portion of a separated body part to its normal location or other suitable location
- Explanation: Vascular circulation and nervous pathways may or may not be reestablished
- Examples: Reattach penis, Reattach finger, Reattachment of severed ear, Replantation of avulsed teeth
Problem #7, Cautery Nosebleed
- Definition: Physical eradication of all or a portion of a body part by the direct use of energy, force or a destructive agent
- Explanation: None of the body part is physically taken out
- Examples: 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)