Coding problem for this week: Left axillary lymph node biopsy.
Answer Key: 07B60ZX
Two weeks ago we began a discussion on the guidelines for biopsies, 3B.4a: Biopsy procedures are coded using the root operations Excision, Extraction, or Drainage and the qualifier Diagnostic. Today we will focus on Excision.
Problem: A sampling of tissue was taken from the left axillary lymph nodes for biopsy. A piece of tissue was cut out of the lymph node and sent to pathology.
To Locate: PCS Index > Biopsy > see Excision with qualifier Diagnostic > Excision > Lymphatic > Axillary > Left > 07B6 > locate table 07B and go across the row to finish building the code after verifying that the 4th character value of 6 is correct:
Excision of Left Axillary Lymph Node, Open Approach, Diagnostic
- How do you know this is an excision rather than another type of biopsy? The problem stated that a sampling of tissue was taken. Remember, in excision procedures only a portion of a body part is cut out. When a lymph node(s) is cut out, the root operation is Excision. When an entire lymph node chain is cut out, the appropriate root operation is Resection.
- The qualifier DIAGNOSTIC is used to identify excision procedures that are biopsies.
Locating the Code(s) by Going Directly to the Tables
Directions for Locating Axillary Lymph Node Biopsy
- The majority of PCS codes are located in the Med/Surg section, which is where you should be; 0 is the 1st character value. Med/Surg procedure codes all have a first character value of 0.
- Determine which Body System you should be in. We are in the Lymphatic/Hemic Body System with a 2nd character value of 7. So far we have identified the 1st 2 characters, 07.
- Then locate the root operation, 3rd character. The root operations are arranged alphabetically. We are looking for Excision, character value B. We are now in the correct table, 07B.
- After identifying the 4th character value of 6, the Body Part for the Left Lymphatic, Axillary, 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. So far we have the character values 07B6.
- It isn’t always easy to determine the Approach. However, the sampling of tissue was cut out and it is considered an Open procedure. Now we’re up to 5 characters, 07B60 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, 07B60ZX.