ICD-10-PCS, Root Operations – Part 15, Procedures: Question & Answer

ICD-10-PCS, Root Operations – Part 15, Procedures: Question & Answer

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.

The lessons for the past several weeks have been rather intense. For the next several weeks we are simply going to get in some PCS practice. There are four coding problems for this week, as follows: 

  1. Excision of malignant melanoma from the skin of the left upper arm and right hand.
  2. Percutaneous needle core biopsy (diagnostic) of the left kidney pelvis.
  3. Sigmoidoscopy with sigmoid polypectomy.
  4. Open resection of descending colon.

Answer Key:

  1. 0FB13ZX
  2. 0BH17EZ
  3. 0SNDXZZ
  4. 0CTPXZZ
  5. 0HB4XZZ
  6. 09M0XZZ
  7. 095KXZZ

 

Problem #1, Needle Biopsy Right Lobe of Liver

To Locate:  PCS Index >Biopsy > see Excision with qualifier Diagnostic > Excision > Liver > Right lobe > 0FB1 > locate table 0FB and go across the row to finish building the code: Root Ops, Part 11 - A

  • 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:

Insertion of endotracheal airway into trachea, via natural or artificial opening Root Ops, Part 11 – B

  • 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:

Release left knee joint, external approach Root Ops, Part 11 – C

  • 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

Root Ops, Part 11 – D

  • 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:

Root Ops, Part 11 – E

  • 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:

Root Ops, Part 11 – F

 

  • 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

Root Ops, Part 11 – G

  • 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)

 

We have been discussing approaches for the past 3 weeks, with last week’s tidbit being a quiz  matching various root operations to their respective approaches. This week we are going to practice coding a variety of scenarios that incorporate the approaches. Just a reminder that the 7/28/14 post covered the Percutaneous Endoscopic approach and the 8/5/14 post covered the approach, Via Natural or Artificial Opening Endoscopic.

This week we will code the following approaches:  Percutaneous, Via Natural or Artificial Opening, External and Open. So, let’s get started:

  1. Needle biopsy of right lobe of liver
  2. Endotracheal Intubation
  3. Manual rupture left knee joint
  4. Resection of tonsils
  5. Local excision of skin lesion of neck
  6. Reattachment severed right ear
  7. Cautery Nosebleed

For the past few weeks have been focusing on approaches, Percutaneous Endoscopic and Via Natural or Artificial Opening Endoscopic. This week we will focus on the remaining approaches:

  • Open:  Cutting through the skin or mucous membrane (mm) and any other body layers necessary to expose the site of the procedure.
  • Percutaneous:  Entry, by puncture or minor incision, of instrumentation through the skin or mm and any other body layers necessary to reach and visualize the site of the procedure.
  • Via Natural or Artificial Opening:  Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure.
  • Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance:  Entry of instrumentation through a natural or artificial external opening and entry, by puncture or minor incision through the skin or mm and any other body layers necessary to aid in the performance of the procedure. An LAVH, Laparoscopic-assisted vagina hysterectomy, is an example of this approach, one not that frequently assigned.
  • External:  Procedures performed directly on the skin or mm and procedures performed indirectly by the application of external force through the skin or mucous membrane.

 

Before moving ahead, a quick review of the two approaches previously discussed:

  • Percutaneous Endoscopic:  Entry, by puncture or minor incision, of instrumentation through the skin or mm and any other body layers necessary to reach and visualize the site of the procedure.
  • Via Natural or Artificial Opening Endoscopic:  Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure.

 

Test yourself on how well you understand the various approaches by matching the root operation to the approach in the following exercise. Please note that the approach, Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance, is not included in the following quiz.

 

Match the root operations with the approaches:

  1. Open:  ________________________
  2. Percutaneous:  __________________
  3. Endoscopic:  ___________________
  4. Via Natural or Artificial Opening: ______________
  5. Via Natural or Artificial Opening Endoscopic: __________________________________
  6. External:  ______________________

 

A. Resection of Tonsils

B. CABG

C. Percutaneous needle core biopsy kidney

D. Transurethral cysto w/ removal bladder stone

E. Excision skin lesion

F. Liposuction

G. Endoscopic ERCP

H. Abdominal hysterectomy

I. Colonoscopy

J. Closed reduction fracture

K. Percutaneous drainage ascites

L. Foley catheter placement

M. Digital rectal exam

N. Laparoscopic cholecystectomy

O. Needle biopsy liver

P. Cautery nosebleed

Q. Open endarterectomy

R. Manual rupture joint adhesions

S. Endotracheal intubation

T. Arthroscopy

U. Transvaginal intraluminal cervical cerclage

V. Endoscopic drainage sinus

W. EGD

X. Laparoscopy with destruction endometriosis

Y. Reattachment severed ear

Z. Hysteroscopy

 

 

 

 

 

Who We Are

 

 

 

 

 

Answer Key:

 

  1. Open:  B, H, Q
  2. Percu: C, F, K, O
  3. Endo:  N, T, V, X
  4. Nat/Art Open:  L, M, S, U
  5. Nat/Art Open Endo:  D, G, I, W, Z
  6. Ext:  A, E, J, P, R, Y

Answer key:

  1. 0TCB8ZZ
  2. 0UJD8ZZ
  3. 0DJD8ZZ
  4. 0DJ08ZZ

 

Problem #1, Transurethral cystoscopy with removal of bladder stone

To locate:  PCS Index >Extirpation >Bladder > 0TCB > locate table 0TC and then go across the row to finish building the code:

Extirpation of matter from bladder, via natural or artificial opening endoscopic

Part 9, A

  • If you go to the PCS Index and refer to the main term/the root operation, Cystoscopy, the code listed is 0TJB8ZZ, Inspection of Bladder. This is not the correct code, so what do you do now? The easiest and quickest method is to refer to the Root Operations glossary located in the front of the ICD-10-PCS coding book. “Removal” is out because it pertains only to the removal of devices. Removal of a bladder stone falls under the definition of Extirpation, “Taking or cutting out solid matter from a body part.”
  • Another method is to bypass the Index altogether and go directly to the tables. First go to the Med/Surg section and then determine the body system, Urinary. Then scan the root operations (character #3), an alpha list looking for Extirpation. You are now in the correct table, 0TC.

 

 

Problem #2, Hysteroscopy

To Locate:  PCS Index > 0UJD8ZZ > Since you should never code from the Index, we’re going to refer to the table 0UJ and go across the row to verify that the code is correct:

Inspection of uterus and cervix, via natural or artificial opening endoscopic

Part 9, B

 

 

Problem #3, Diagnostic Colonoscopy in a colostomy patient

To Locate:  PCS Index > Colonoscopy >0DJD8ZZ

This is such a commonly performed procedure the PCS Index gives the entire code. However, you should never code from the Index. That being said, let’s verify the code:

Inspection of lower intestinal tract, via natural or artificial opening endoscopic

Part 9, C

  • In ICD-10-PCS it makes no difference whether the scope is inserted through the colostomy stoma rather than through the anus, but in ICD-9-CM, it does impact code assignment.  In ICD-10-PCS the colostomy stoma is an artificial opening and since the definition of this approach includes artificial opening, we’re good to go.

 

 

Problem #4, EGD

To Locate:  PCS Index > 0DJ08ZZ > Since we never code from the index, locate table 0DJ and go across the row to verify that the code is correct:

Inspection of upper intestinal tract, via natural or artificial opening endoscopic

Part 9, D

 

SUMMARY

The common element shared by these four procedures is the approach, Via Natural or Artificial Opening Endoscopic. Regardless of the type of procedure carried out, 3 out of 4 procedures were accomplished by utilizing the body’s natural orifices. In problem #1, the urethra was used to access the bladder; in problem #2, the vagina was used to access the uterus; in problem #3, the colostomy site (artificial opening) was used to access the colon; in problem #4, the oral cavity was used to access upper GI tract.

 

From the Blog

ICD-10-PCS, Root Operations – Part 15, Procedures: Question & Answer

Questions for this week: Cystoscopic dilation of right ureteral stricture, with stent placement read more