Coding Tidbits Written By: Linda Kobayashi
Edited and Posted By: Andrea Wong
Hello there, Busters. In a few more months we will all be coding from the ICD-10 code set, ready or not. We hope these weekly tidbits have been helpful. We’re trying to do our best to help you prepare. This week we are giving you two problems to solve related to the prostate. It is a good exercise because when coding, you will be able to compare the similarities and differences between the 2 coding problems.
There are a few changes we are going to point out for our new readers. For the past few weeks we have given you coding problems that require assignment of both diagnoses and procedures. With respect to the breakdown of diagnostic codes, a new feature, we will only do that for the PDx. However, this week’s PDx only has 3 digits, so there is nothing to break down. This week you will be given 2 problems to solve from Diseases of the Genitourinary System, Chapter 14. Also, directions for locating the codes by using the tables only applies to the principal procedure and for this week, it will be for the second problem, and will be the last item discussed.
Problems for the week:
1.) A 55-year-old man was anuric and diagnosed with prostate cancer for which he underwent an open radical retropubic prostatectomy.
2.) A resident from an assisted living home complained of a sensation of incomplete bladder emptying, and was immediately taken to surgery where a transurethral endoscopic laser ablation of the prostate was done upon admission to an acute care hospital. Final diagnosis is BPH.
1.) C61 = Malignant neoplasm of the prostate
R34 = Anuria and oliguria
0VT00ZZ = Radical retropubic prostatectomy, open
2.) N40.1 = Benign Prostatic Hypertrophy (enlarged prostate) with lower urinary tract symptoms (LUTS)
R39.14 = Feeling of incomplete bladder emptying
0V508ZZ = Destruction of prostate, via natural or artificial opening, endoscopic
Problem #1, To Locate C61: Disease Index > Neoplasm Table > 1st column, Malignant Primary > prostate > C61 > verify in Tabular.
To Locate R34: Disease Index > Anuria > R34 > verify in Tabular.
- Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis. The definitive diagnosis should be sequenced before the symptom code.
- In this case, not every patient who has prostate cancer routinely has the symptoms of anuria. Hence, anuria is coded, and sequenced after C61.
To locate 0VT00ZZ: PCS Index > Prostatectomy > see Resection, Prostate > 0VT0 > locate table 0VT and go across the row to finish building the code and also verify that the 4th character is correct:
Resection of Prostate, Open Approach
- Resection is defined as “Cutting out or off, without replacement, all of a body part.”
- The Index gives you a choice of excision or resection. We know the entire prostate was removed because in our diagnostic statement it states that the prostatectomy was radical.
Problem #2, To locate N40.1/R39.14: Disease Index > Hypertrophy, hypertrophic > prostate > see Enlargement, enlarged, prostate > with lower urinary tract symptoms (LUTS) > N40.1 > Verify in tabular > Instructional Note: Use additional code for associated symptoms, when specified > incomplete bladder emptying > R39.14 > Verify both codes in Tabular.
- 1 is a combination code that includes both the enlarged prostate, Benign Prostatic Hypertrophy (BPH) and the lower urinary tract symptom of incomplete bladder emptying.
- In the Index in red font there is a list of symptoms associated with LUTS. Select the most appropriate symptom.
To locate 0V508ZZ: PCS Index > Destruction > Prostate > 0V50 > locate table 0V5 and go across the row to finish building the code. Also verify that the 4th character value is correct:
Destruction of Prostate, Via Natural or Artificial Opening Endoscopic
- In both instances, the prostate was removed/destroyed but the surgical method employed different techniques.
- In the first example, the prostate was cut out (resected) via an open approach,
- In the 2nd example the prostate was destroyed via laser ablation.
- In the PCS Index, the main term ablation sends you to destruction. Think of ablation and destruction as synonymous terms.
- Destruction 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.” In our example laser was the destructive agent.
Directions for Locating the Codes by Going Directly to the Tables
Resection of prostate, open approach
- Step #1 is to locate the correct section in your PCS coding book. You know that surgery was performed, so the most logical selection is the Med/Surg section. The majority of procedures are in the Med/Surg section. The first character in the Med/Surg section is always 0.
- Step 2: Determine the correct Body System. Since the body part is the prostate, it is only logical that the Body System is the Male Reproductive System. We have identified the first two characters, 0V.
- Step 3: Determine the root operation. You know you have to be in a table that starts with 0V. You should also know that the root operations are listed alphabetically. Simply go through the all the tables that start with 0V and look for the root operation, resection. We now have the first three characters, 0VT, which puts us in the correct table. The first 3 character values are always listed for you at the top of the table. It gives the section, Med/Surg; the body system, Male Reproductive; the root operation, Resection.
- Step 4: Identify the Body Part to determine the 4th character value. The Body Part, prostate, should relate to the root operation, Resection, because it was the prostate that was resected. We now have 4 character values 0VT0.
- Step 5: Determine the Approach. No guesswork regarding the approach, as our diagnostic statement clearly states that the procedure was done via an open approach. We should now have 5 characters, 0VT00.
- Step 6: Determine whether or not a device was left in the patient postoperatively. No device was left in place, so assign Z, the placeholder, as the character value. We should now have 6 characters, 0VT00Z.
- Step 7: There is no qualifier, so we should now have our code, 0VT00ZZ. Z functions as a placeholder in ICD-10-PCS. In other words, Z is to PCS what X is to ICD-10-CM.