This week and for the following few weeks, rather than addressing specific PCS guidelines, I’m giving you a problem from the Med/Surg section, randomly selected. Any guidelines that apply to this problem will, of course, be discussed.
Problem for this week: Colonoscopy, abandoned at sigmoid colon.
Answer Key: 0DJD8ZZ
To Locate: PCS Index > Sigmoidoscopy > 0DJD8ZZ > go to table 0DJ and verify that the last 3 character values are correct. In addition, verify that the root operation is correct:
Inspection of Lower Intestinal Tract, Via Natural or Artificial Opening Endoscopic
- We really got a break with this problem. However, I still want you to locate table 0DJ and go across the row to verify that the character values given in the Index are correct.
- Guideline B3.3 for Discontinued Procedures:
- Method 1: If the intended procedure is discontinued, code the procedure to the root operation performed. The root operation performed would be located under Sigmoidoscopy.
- Method 2: If the procedure is discontinued before any other root operation is performed, code the root operation Inspection of the body part or anatomical region inspected.
- The root operation in the Index would be located under Inspection.
- To locate the code: Inspection > Intestinal Tract > Lower > 0DJD.
- To determine whether the sigmoid is part of the lower or upper GI tract, refer to Guideline B4.8, which explains that the lower Intestinal tract “includes the portion of the GI tract from the jejunum down to and including the rectum and anus.”
- Understanding the anatomy for the Digestive System is important for locating codes in the Index or tables.
Locating the Code(s) by Going Directly to the Tables
Directions for Sigmoidoscopy
- 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 sigmoid colon is part of the Gastrointestinal System, 2nd character value of D. So far we have identified the 1st 2 characters, 0D.
- Then locate the root operation, 3rd character. The root operations are arranged alphabetically. We are looking for Inspection, character value J. We are now in the correct table, 0DJ.
- After identifying the 4th character, D, the Body Part for lower intestinal tract, 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 4th character value as well. So far we have the character values 0DJD.
- It isn’t always easy to determine the Approach. However, we know that, unless stated otherwise, the scope is inserted through a natural opening, the anus. Now we’re up to 5 characters, 0DJD8 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 there is no Qualifier, the character value is Z.