Coding problem for this week:
- Fine needle aspiration biopsy of left lower lobe of lung via inserting a thin needle into the tumor.
For the next 3 weeks we are going to review the PCS coding guidelines for biopsies, focusing on guideline B3.4a, Biopsy procedures. According to this guideline:
Biopsy procedures are coded using the root operations Excision, Extraction, or Drainage and the qualifier Diagnostic. The qualifier Diagnostic is used only for biopsies. Examples: Fine needle aspiration biopsy of lung is coded to the root operation Drainage with the qualifier Diagnostic. Biopsy of bone marrow is coded to the root operation Extraction with the qualifier, Diagnostic. Lymph node sampling for biopsy is coded to the root operation Excision with the qualifier Diagnostic.
For practice, we are going to code the 1st example given in the above-referenced guideline, B3.4a.
Problem #1, Fine needle aspiration biopsy of left lower lobe of lung via inserting a thin needle into the tumor.
To Locate: PCS Index > Biopsy > see Drainage with qualifier Diagnostic > Lung > Lower Lobe > Left > 0B9J > Locate table 0B9 and go across the row to finish building the code after verifying that the 4th character value of J is the correct body part:
Drainage of Left Lower Lung Lobe, Percutaneous Approach, Diagnostic
- Definition 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.
- Definition Percutaneous: 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.
- The approach is considered Percutaneous because a puncture is made in order to insert the needle.
Locating the Code(s) by Going Directly to the Tables
Directions for Fine Needle Aspiration Biopsy
- The majority of PCS codes are located in the Med/Surg section, which is where you should be; 0 is for the 1st character value. If you’re not sure of the correct section, start out by flipping through the various body systems in the Med/Surg section of the coding book.
- Determine which Body System you should be in. You know that the lungs are part of the Respiratory System, 2nd character value of B. So far we have identified the 1st 2 characters, 0B.
- Then locate the root operation, 3rd character. The root operations are arranged alphabetically. We are looking for Drainage, character value 9. We are now in the correct table, 0B9.
- After identifying the 4th character, J, the Body Part for the left lower lobe of lung, you have only 3 characters left to assign. At no time do you have to assign 7 characters because the tables ALWAYS give you the first 3 character values and sometimes the Index gives you the first 4 character values. So far we have the character values 0B9J.
- It isn’t always easy to determine the Approach. However, we know that a puncture had to be made before the needle could be inserted, so the approach is Percutaneous. Now we’re up to 5 characters, 0B9J3 with 2 character values left to go, Device and Qualifier.
- Since no device was used or left in place postoperatively, the 6th character value is Z, the PCS placeholder.
- The 7th and last character value is the Qualifier. Since a biopsy was done, assign X to indicate that the procedure is diagnostic. Now we have our code, 0B9J3ZX.
Character Meanings for the Medical and Surgery Section (0)
A review of the character meanings in the Med/Surg section should be helpful. We are not planning to post this table every week but you can always find it on our website tidbit blog. Look for the tidbit dated 3/26/15.