Basic ICD-10-CM/PCS Coding, Exercises of Biomedicine

Download Basic ICD-10-CM/PCS Coding and more Exercises Biomedicine in PDF only on Docsity!

Basic ICD-10-CM/PCS

Coding

2013 Edition

Answer Key

Lou Ann Schraffenberger, MBA, RHIA, CCS, CCS-P, FAHIMA

Answer Key

The answer key includes the correct ICD-10-CM/PCS codes and the Alphabetic Index entry used to

locate each code.

Chapter 1

Introduction to ICD-10-CM

Exercise 1.

1. N63 Mass, breast
2. N13.30 Hydronephrosis (primary)
3. J34.2 Deviated, nasal septum
4. R59.0 Adenopathy, inguinal
5. I25.10 Disease, arteriosclerotic—see Disease, heart, ischemic, atherosclerotic. Arteriosclerotic heart—see Arteriosclerosis, coronary (artery)
6. G44.209 Headache, tension
7. K85.9 Pancreatitis (suppurative)
8. K00.6 Eruption, tooth abnormal (premature)
9. I33.0 Endocarditis, infectious
10. I08.0 Endocarditis, mitral with aortic (valve) disease, active or acute

Exercise 1.

1. Nonessential modifier = congenital Q67.8 Distortion (congenital) chest (wall)
2. Nonessential modifier=acute K57.32 Diverticulitis (acute) intestine, large
3. Nonessential modifier = bleeding K64.4 Hemorrhoids external
4. Nonessential modifier=cardiac R01.0 Murmur (cardiac) functional
5. Nonessential modifier=chronic J32.0 Sinusitis (chronic) maxillary

Exercise 1.

1. Main term=Endomyometritis N71.0 Endomyometritis—see Endometritis, acute
2. Main term=Metrorrhexis N85.8 Metrorrhexis—see Rupture, uterus, nontraumatic
3. Main term=Osteoarthrosis M19.019 Osteoarthrosis—see also Osteoarthritis, shoulder, M19.01- (unspecified = M19.019) 4. Main term=Prolapse M50.20 Prolapse—see Displacement, intervertebral disc, cervical 5. Main term=Stenosis N88.2 Stenosis, endocervical—see Stenosis cervix

Exercise 1.

1. A41.9 Sepsis NOS
2. A49.8 Infection, bacteroides NEC
3. I31.9 Pericarditis (with effusion)
4. B08.3 Disease, fifth Tabular List—B08.3—Erythema infectiosum [fifth disease]
5. Dementia, with, Lewy bodies G31. [F02.80] See the "Use additional code" note under category G Use additional code to identify dementia with behavioral disturbance (F02.81) Use additional code to identify dementia without behavioral disturbance (F02.80)

Exercise 1.

1. Intrahepatic bile duct
2. Diabetes mellitus arising in pregnancy Gestational diabetes mellitus
3. Anorexia nervosa
4. Blackout, Fainting, Vasovagal attack
5. Diverticulum of appendix

Exercise 1.

1. I85.11 Varix, esophagus, in, cirrhosis of liver, bleeding
2. N39.0 Infection, urinary (tract) Use additional code (B95–B97) to identify infectious agent B96.20 Infection, Escherichia coli as cause of disease classified elsewhere
3. K26.0 Ulcer, duodenum, acute, with hemorrhage
4. P61.2 Anemia, due to, prematurity
5. Z04.1 Examination, following, motor vehicle accident

Chapter 2

Introduction to ICD-10-PCS

Review Exercises: Chapter 2

1. Answer: 0DJO8ZZ Character Code Explanation Section 0 Medical and Surgical Body Syst em

D Gastrointestinal System

Root Ope ratio n

J Inspection

Body Part 0 Upper Intestinal Tract Approach 8 Via Natural or Artificial Opening Endoscopic Device Z No Device Qualifier Z No Qualifier

INDEX: Root Operation: Inspection. Index: Esophagogastroduodenoscopy (0DJ08ZZ)

In this example, the complete seven character code is listed in the Index. The code still must be confirmed using the code Tables. EGD is an inspection procedure when no other procedures, such as a biopsy or excision, are performed with the EGD. Body part inspected is the upper intestinal tract. Approach is through the mouth so “via natural or artificial opening endoscopic” is the choice for this procedure.

2. Answer: 0HBU0ZZ Character Code Explanation Section 0 Medical and Surgical Body System H Skin and Breast Root Oper ation

B Excision

Body Part U Breast, Left Approach 0 Open Device Z No Device Qualifier Z No Qualifier

INDEX: When consulting the Index, the main term Mastectomy has two subterms: see Excision, Skin and Breast and see Resection, Skin and Breast. Since only part of the breast was removed, the root operation is Excision.

3. Answer: 041L0KL Character Code Explanation Section 0 Medical and Surgical Body Syste m

4 Lower Arteries

Root Oper ation

1 Bypass

Body Part L Femoral Artery, Left Approach 0 Open Device K Nonautologous Tissue Substitute Qualifier L Popliteal Artery

INDEX: When consulting the Index, the main term Bypass, subterm Artery, Femoral produced the root operation table of 041. According to ICD-10-PCS guideline B3.6a.Bypass procedures: Bypass procedures are coded by identifying the body part bypassed “from” and the body part bypassed “to”. The fourth character body part specifies the body part bypassed from, and the qualifier specifies the body part bypassed to. In this example, the bypass was “from” the femoral artery “to” the popliteal artery. A cadaver vein graft is the device identified as nonautologous (from another human than patient) tissue substitute.

4. Answer: 0UN24ZZ Character Code Explanation Section 0 Medical and Surgical Body Syste m

U Female Reproductive System

Root Opera tion

N Release

Body Part 2 Ovaries, Bilateral Approach 4 Percutaneous Endoscopic Device Z No Device Qualifier Z No Qualifier

INDEX: Lysis see Release. Release, Ovaries, Bilateral (0UN2) Definition of release in ICD10-PCS is freeing a body part from an abnormal physical constraint which also describes a procedure identified as lysis. Two codes are required for this procedure as the same root operation is performed on different body parts as defined by distinct values of the body part character for the root operation

“release.” Laparoscopy is an approach that is percutaneous endoscopic

Answer: 0UN74ZZ Character Code Explanation Section 0 Medical and Surgical Body System

U Female Reproductive System Root Operation

N Release

Body Part 7 Fallopian Tubes, Bilateral Approach 4 Percutaneous Endoscopic Device Z No Device Qualifier Z No Qualifier

INDEX: Lysis see Release. Release, Fallopian Tubes (0UN7)

5. Answer: 0SG10A Character Code Explanation Section 0 Medical and Surgical Body System S Lower Joints Root Operation

G Fusion

Body Part 1 Lumbar Vertebral Joints, 2 or more Approach 0 Open Device A Interbody Fusion Device Qualifier 1 Posterior Approach, Posterior Column

INDEX: Root operation is fusion. Index: Fusion, lumbar vertebrae 2 or more (0SG1). According to the ICD-10-PCS guideline for fusion procedures of the spine, B3.10a: The body part coded for a spinal vertebral joint(s) rendered immobile by a spinal fusion procedure is classified by the level of the spine (e.g. thoracic). There are distinct body part values for a single vertebral joint and for multiple vertebral joints at each spinal level. According to guideline B3.10.c if an interbody fusion device is used to render the joint immobile (alone or containing other material like bone graft), the procedure is coded with the device value Interbody Fusion Device. The qualifier identifies the combination of the approach and the column.

6. Answer: 0TP98DZ Character Code Explanation Section 0 Medical and Surgical Body System T Urinary System Root Operation

P Removal

Body Part 9 Ureter Approach 8 Via Natural or Artificial Opening Endoscopic Device D Intraluminal Device Qualifier Z No Qualifier

INDEX: Root Operation: Removal. Index: Removal of device from, Ureter (0TP9) The objective of the procedure was to take the stent out of the ureter which matches the definition of “removal” to take out of off a device from a body part. The approach is by cystoscopy or via natural or artificial opening (urethra) endoscopic. A stent is an intra-luminal device which are devices placed inside tubular body parts.

7. Answer: 0XMJ0ZZ Character Code Explanation Section 0 Medical and Surgical Body System

X Anatomical Region, Upper Extremities Root Operation

M Reattachment

Body Part J Hand, Right Approach 0 Open Device Z No Device Qualifier Z No Qualifier

INDEX: Root Operation: Reattachment_._ Index: Reattachment, Hand, Right (0XMJ0ZZ) Index provides a specific code for this operation. The only variable on the Table is the body part being reattached.

8. Answer: 0W9G3ZX Character Code Explanation Section 0 Medical and Surgical Body System

W Anatomical Regions, General Root Operation

9 Drainage

Body Part G Peritoneal Cavity Approach 3 Percutaneous Device Z No Device Qualifier X Diagnostic

INDEX: Root Operation: Drainage Index: Paracentesis, Peritoneal Cavity see Drainage,

12. Answer: 0QSG0ZZ Character Code Explanation Section 0 Medical and Surgical Body System Q Lower Bones Root Operation

S Reposition

Body Part G Tibia, Right Approach 0 Open Device Z No Device Qualifier Z No Qualifier

INDEX: Root Operation: Reposition. Index: Reduction, fracture, see reposition. Reposition, Tibia, Right (0QSG). There is no device used for this question because no fixation device is included in the procedure title. The device character would change depending on the type of fixation device use, if any.

13. Answer: 02RG08Z Character Code Explanation Section 0 Medical and Surgical Body System

2 Heart and Great Vessels

Root Operation

R Replacement

Body Part G Mitral Valve Approach 0 Open Device 8 Zooplastic Tissue Qualifier Z No Qualifier

INDEX: Root Operation: Replacement. Index: Replacement, Valve, Mitral (02RG) The coder needs to complete the code with the approach (open), the device (porcine which is animal or zooplastic tissue) and the default “Z” for no qualifier.

14. Answer: 02703ZZ Character Code Explanation Section 0 Medical and Surgical Body System

2 Heart and Great Vessels

Root Operation

7 Dilation

Body Part 0 Coronary Artery, One Site Approach 3 Percutaneous Device Z No Device Qualifier Z No Qualifier

INDEX: Root Operation: Dilation. Index: Angioplasty—see Dilation, Heart and Great Vessels. Index: Dilation, artery, coronary, one site (0270) Also the option “PTCA” see Dilation, Heart and Great Vessels (027) The coding of a PTCA procedure depends on coronary artery lesion sites (See guideline B4.4) involved (body part), the approach (usually percutaneous) and whether or not a stent (and what type) is used for the device character. Bifurcation for a qualifier option is to identify when a procedure is performed at site of a vessel’s bifurcation.

15. Answer: 0D5N8ZZ Character Code Explanation Section 0 Medical and Surgical Body System

D Gastrointestinal System

Root Operation

5 Destruction

Body Part N Sigmoid Colon Approach 8 Via Natural or Artificial Opening Endoscopic Device Z No Device Qualifier Z No Qualifier

INDEX: Root Operation: Destruction. Index: Fulguration—see Destruction. Destruction, colon, sigmoid (0D5N.) Usually, a procedure like this example is titled colonoscopy with fulguration of polyp. The coder must complete the code with the approach (endoscopic via natural opening to reach a colonic polyp) and there is no option for a device or a qualifier.

16. Answer: 05CD0ZZ Character Code Explanation Section 0 Medical and Surgical Body System 5 Upper Veins Root Operation

C Extirpation

Body Part D Cephalic Vein, Right Approach 0 Open Device Z No Device Qualifier Z No Qualifier

INDEX: Root Operation: Extirpation. Thrombectomy-see Extirpation. Index: Extirpation, Vein, Cephalic, Right (05CD) Again, the coder must complete the coder with the approach (open=by incision) but no options for device or qualifier.

17. Answer: 0SWD0JZ Character Code Explanation Section 0 Medical and Surgical Body System S Lower Joints Root Operation

W Revision

Body Part D Knee Joint, Left Approach 0 Open Device J Synthetic Substitute Qualifier Z No Qualifier

INDEX: Root Operation: Revision. Index: Revision of device in, joint, knee, left (0SWD)Coder needs to complete 5th^ character for approach (open), 6 th^ character for device (joint prosthesis are metal or ceramic, which are synthetic substitutes for the joint) and no option for qualifier

INDEX: Root Operation: Restriction. Index: Banding—see Restriction, Artery, Pulmonary, Right (02VQ.) The root operation “restriction” is defined as partially closing an orifice or the lumen of a tubular body part. A banding procedure puts a device on a tubular body part to partially close the lumen. Approach is open as a thoracotomy. Device is specified in procedure title as an extraluminal device that is the actual banding of the vessel. Extraluminal—outside the tube/vessel.23.

23. Answer: 04LE3DT Character Code Explanation Section 0 Medical and Surgical Body System

4 Lower Arteries

Root Operation

L Occlusion

Body Part E Internal Iliac Artery, Right Approach 3 Percutaneous Device D Intraluminal Device Qualifier T Uterine Artery, Right

INDEX: Root Operation: Occlusion. Index: Embolization—see Occlusion, artery, internal iliac, right uterine artery, right (04LE) There is no entry in the Index for artery, uterine. Using the Body Part Key, the uterine artery is used as the internal iliac artery for the body part character. The Device Key is used to identify that embolization coil is an intraluminal device for the device character. The Qualifier “T” identifies the uterine artery as the site of the procedure.

24. Answer: 0W4M0K Character Code Explanation Section 0 Medical and Surgical Body System

W Anatomical Regions, General

Root Operation

4 Creation

Body Part M Perineum, Male Approach 0 Open Device K Nonautologous Tissue Substitute Qualifier 0 Vagina

INDEX: Creation. The coder must know the definition of the root operations so that the root operation of “creation” is accessed in the Index. Index: Creation, male, should be used as it is a male patient having the procedure. The body part of the male where the procedure is performed is the perineum. The device of tissue bank donor material

is nonautologous or other human tissue. The Qualifier identifies that a vagina is being created.

25. Answer: 0H0V0JZ Character Code Explanation Section 0 Medical and Surgical Body System

H Skin and Breast

Root Operation

0 Alteration

Body Part V Breast, Bilateral Approach 0 Open Device J Synthetic Substitute Qualifier Z Qualifier

INDEX: Root Operation: Alteration. Coder must recognize this is a cosmetic procedure, therefore, the root operation is alteration. Index: Alteration, breast, bilateral (0H0V) The silicone implants are the device which is a synthetic substitute.

26. Answer: 00HV3MZ Character Code Explanation Section 0 Medical and Surgical Body System

0 Central Nervous System

Root Operation

H Insertion

Body Part V Spinal Cord Approach 3 Percutaneous Device M Neurostimulator Lead Qualifier Z No Qualifier

INDEX: Root Operation: Insertion. Index: Insertion of device in, spinal cord (00HV). The device is a neurostimulator which is inserted into lumbar spinal cord by percutaneous approach.

27. Answer: 0UUG0JZ Character Code Explanation Section 0 Medical and Surgical Body System

U Female Reproductive System

Root Operation

U Supplement

Body Part G Vagina Approach 0 Open Device J Synthetic Substitute Qualifier Z No Qualifier

INDEX: Root Operation: Supplement. Index: Colporrhaphy see Repair, Vagina (0UQG) When reviewing this table, coder will note there is no device character to identify the mesh used. So this is

not the correct root operation. The definition of supplement is putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part. The insertion of mesh is a “supplement” procedure that reinforces the structure of the body part. The Index entry to be used is Supplement, vagina (0UUG). Mesh is a synthetic product.

28. Answer: 0B21XFZ Character Code Explanation Section 0 Medical and Surgical Body System

B Respiratory System

Root Operation

2 Change

Body Part 1 Trachea Approach X External Device F Tracheostomy Device Qualifier Z No Qualifier

INDEX: Root Operation: Change. Index: Exchange see Change device in, trachea (0B21). An exchange procedure is removing and reinserting the same or similar device into the same location. A tracheostomy tube exchange involved a device in the trachea. The approach is external the tracheostomy opening is accessed directly at the skin level.

29. Answer: 00K00ZZ Character Code Explanation Section 0 Medical and Surgical Body System

0 Central Nervous System

Root Operation

K Map

Body Part 0 Brain Approach 0 Open Device Z No Device Qualifier Z No Qualifier

INDEX: Root Operation: Map. Index: Map, brain (00K0). The approach is open as described by the craniotomy. There is no device left in the body after the procedure and no qualifier listed on the code table.

30. Answer: 0W3G0ZZ Character Code Explanation Section 0 Medical and Surgical Body System

W Anatomical Regions, General Root Operation

3 Control

Body Part G Peritoneal Cavity Approach 0 Open Device Z No Device Qualifier Z No Qualifier

INDEX: Root Operation: Control. The procedure is identified as a control of postoperative bleeding. Index: Control, postprocedural bleeding in, peritoneal cavity (0W3G). The approach is open as described by laparotomy. The body part where the procedure is performed is the peritoneal cavity where the bleeding occurred.

Chapter 4

Certain Infectious and Parasitic

Diseases

Review Exercises: Chapter 4

1. N39.0, Infection, urinary tract B96.4, Infection, bacterial, NOS, as cause of disease classified elsewhere, Proteus (mirabilis) The “Use additional code’ note under N39. instructs the coder to an additional code (B95–B97) to identify the infectious agent.
2. A04.7, Colitis, Clostridium difficile Z16.24, Resistance, to multiple drugs (MDRO) antibiotics ICD-10-CM provides a code to identify drug resistant organisms (Z16). The “use additional code” note is found at the beginning of Chapter 1.
3. A02.9, Poisoning, food, bacterial—see Intoxication, foodborne, due to Salmonella Another entry is Poisoning, food, due to, Salmonella. Food poisoning is classified to Chapter 1, Certain infectious and parasitic disease (A00–B99). If gastroenteritis is documented, then the code would change to A02.0.
4. A56.11, Salpingitis, chlamydial
5. B20, AIDS C46.0 Sarcoma, Kaposi's, skin (multiple)
6. A41.81 Sepsis, Enterococcus K57.40 Diverticulitis, intestine, large, with small intestine, with perforation
7. A41.3 Sepsis, Haemophilus influenzae R65.21 Sepsis, severe, with septic shock N17.9 Failure, renal acute
8. A37.01 Whooping cough, due to Bordetella, pertussis, with pneumonia
9. B16,2 Hepatitis, B, acute, with, hepatic coma
10. B37.81, Esophagitis, candidal A combination code exists in ICD-10-CM to identify the myotic condition of candidiasis

occurring in the esophagus and causing an esophagitis condition.

11. PROCEDURE: Insertion of multilumen central venous catheter into the right subclavian vein for intravenous infusion by percutaneous approach Character Code Explanation Section 0 Medical and Surgical Body System

5 Upper Veins

Root Operation

H Insertion

Body Part 5 Subclavian Vein, Right Approach 3 Percutaneous Device 3 Infusion Device Qualifier Z No Qualifier

INDEX: Insertion of device in, vein, subclavian, right 05H

12. PROCEDURE: Exploratory laparotomy and small-bowel resection of 50 cm portion of the jejunum with side-to-side, functional end-to-end sewn anastomosis of the jejunum. The patient has peritonitis and a twisted nonviable small bowel. Character Code Explanation Section 0 Medical and Surgical Body System

D Gastrointestinal System

Root Operation

B Excision

Body Part A Jejunum Approach 0 Open Device Z No Device Qualifier Z No Qualifier

INDEX: Excision, jejunum 0DBA. The physician states resection but according to the definition of the root operations resection and excision, this operation is an excision because only a portion of the small bowel/jejunum. The approach is open as stated by exploratory laparotomy. Anastomosis should not be assigned separately. New coding guideline in 2013. B3.1b Components of a procedure specified in the root operation definition and explanation are not coded separately. Procedural steps necessary to reach the operative site and close the operative site, including anastomosis of a tubular body part, are also not coded separately. Example : Resection of a joint as part of a joint replacement procedure is included in the root operation definition of Replacement and is not coded separately. Laparotomy performed to reach the site of an open liver biopsy is not coded separately. In a resection of

sigmoid colon with anastomosis of descending colon to rectum, the anastomosis is not coded separately.

13. PROCEDURE: Insertion of venous access device/port percutaneously into the subclavian vein advanced to the superior vena cava with a pocket for the port placed in the subcutaneous tissue of the chest wall for chemotherapy to treat colon carcinoma. An incision is made to create the pocket. Character Code Explanation Section 0 Medical and Surgical Body System

2 Heart and Great Vessels

Root Operation

H Insertion

Body Part V Superior Vena Cava Approach 3 Percutaneous Device 3 Infusion Device Qualifier Z No Qualifier

INDEX: Insertion of device into vena cava, superior 02HV. The infusion device catheter is inserted into the superior vena cava by percutaneous approach with the device remaining in the vessel

13. PROCEDURE: Insertion of VAD portion of procedure described above Character Code Explanation Section 0 Medical and Surgical Body System

J Subcutaneous Tissue and Fascia Root Operation

H Insertion

Body Part 6 Subcutaneous Tissue and Fascia, Chest Approach 0 Open Device X Vascular Access Device Qualifier Z No Qualifier

INDEX: Insertion of device into subcutaneous tissue, chest 0JH6. The venous access port is placed in the subcutaneous tissue in the chest wall. This is an insertion of device left in place in the subcutaneous tissue. The coder should not use the Index entry of “insertion of device, in chest wall” because the chest wall is a different anatomic deeper location.. The approach is open because an incision is made. The device is not specified as a “reservoir” so the device “X” is chosen for the VAD.

14. PROCEDURE: Low anterior sigmoid colon ( cm) open resection with end-to-end anastomosis of sigmoid to sigmoid colon. Character Code Explanation Section 0 Medical and Surgical Body System

D Gastrointestinal System

Root Operation

B Excision

Body Part N Sigmoid Colon Approach 0 Open Device Z No Device Qualifier Z No Qualifier

INDEX: Excision, colon, sigmoid 0DBN. The procedure is an excision because only 30 cm of sigmoid colon was removed. Anastomosis should not be assigned separately. New coding guideline in

2013. This procedure is an excision with colostomy creation. Guideline B3.1b

Components of a procedure specified in the root operation definition and explanation are not coded separately. Procedural steps necessary to reach the operative site and close the operative site, including anastomosis of a tubular body part, are also not coded separately. Example : Resection of a joint as part of a joint replacement procedure is included in the root operation definition of Replacement and is not coded separately. Laparotomy performed to reach the site of an open liver biopsy is not coded separately. In a resection of sigmoid colon with anastomosis of descending colon to rectum, the anastomosis is not coded separately.

15. PROCEDURE: Removal of implanted infusion port from the subcutaneous tissue in patient’s chest by incision following completion of infusion therapy Character Code Explanation Section 0 Medical and Surgical Body System

J Subcutaneous Tissue and Fascia Root Operation

P Removal

Body Part T Subcutaneous Tissue and Fascia, Trunk Approach 0 Open Device 3 Infusion Device Qualifier Z No Qualifier INDEX: Removal of device from, subcutaneous tissue and fascia, trunk 0JPT (Chest) by incision or open approach. An implanted infusion port is an infusion device that is different from a venous access device or a reservoir

was excised) because the patient is still receiving chemotherapy. The acquired absence of the pancreas may be coded.

8. Z51.0 Admission for, radiation therapy (antineoplastic) C61 Carcinoma, see also Neoplasm, by site, malignant. Refer to Neoplasm Table, by site, prostate , malignant, primary site

The reason for the encounter (radiation therapy) is the first listed diagnosis. The neoplasm is coded as current as the tumor has not been excised and the patient is receiving radiation therapy. Coding guideline I.C.2.e.2 describes the coding of encounters solely for administration of radiation therapy

9. C78.01 Metastatic, cancer, to specific site— see Neoplasm, secondary by site Neoplasm, lung, (right) , malignant secondary Z85.528 History, personal, malignant neoplasm, kidney Z92.21 History, personal, chemotherapy for neoplastic condition Z92.3 History, personal, radiation therapy

The reason for the visit is evaluation of the metastatic carcinoma of the lung which is the first-listed code. History of kidney cancer which was the primary site was coded as a secondary diagnosis. Also coded was the patient’s history of receiving chemotherapy and radiation therapy

10. C7A.022 Tumor, carcinoid, malignant, ascending colon E34.0 Syndrome, carcinoid

The patient was seen during this visit for the malignant carcinoid tumor in the ascending colon. In addition the patient was treated for the carcinoid syndrome that is a result of the carcinoid tumor. A “use additional code” note to identify any associated endocrine syndrome, such as: carcinoid syndrome (E34.0) appears under category C7A, Malignant neuroendocrine tumors.

11. PROCEDURE: Ultrasound probe-guided prostate needle biopsy via rectum. One needle core biopsy submitted for diagnostic evaluation. Character Code Explanation Section 0 Medical and Surgical Body System

V Male Reproductive System

Root Operation

B Excision

Body Part 0 Prostate Approach 7 Via Natural or Artificial Opening Device Z No Device Qualifier X Diagnostic

INDEX: Biopsy see Excision with qualifier diagnostic. Excision, prostate 0VB0. The needle biopsy is done to obtain tissue for pathological examination for a definitive diagnosis. If multiple prostate biopsies were performed, the code 0VB07ZX would be assigned for each biopsy taken according to ICD-10-PCS guideline B3.2b to code multiple procedures when the same root operation is repeated at different body sites that are included in the same body part value (prostate.) The approach performed through the rectum is assigned the approach of “via natural or artificial opening.”

PROCEDURE: Ultrasound portion of procedure described above Character Code Explanation Section B Imaging Body System

V Male Reproductive System

Root Type 4 Excision Body Part 9 Prostate and seminal vesicles Contrast Z Via Natural or Artificial Opening Device Z None Qualifier Z None INDEX: Ultrasonography, prostate and seminal vesicles BV49ZZZ

12. PROCEDURE: Right breast lumpectomy with sentinel lymph node biopsy, right axilla Character Code Explanation Section 0 Medical and Surgical Body System

H Skin and Breast

Root Operation

B Excision

Body Part T Breast, Right Approach 0 Open Device Z No Device Qualifier Z No Qualifier

INDEX: Lumpectomy see Excision, breast, right 0HBT. Lumpectomy is an open procedure The lumpectomy is a therapeutic procedure to remove a tumor within the breast.

PROCEDURE: Sentinel node biopsy, right axilla Character Code Explanation Section 0 Medical and Surgical Body System

7 Lymphatic and Hemic Systems Root Operation

B Excision

Body Part 5 Lymphatic, Right Axillary Approach 0 Open Device Z No Device Qualifier X Diagnostic INDEX: Biopsy, see Excision, lymphatic, axillary, right 07B5. Sentinel node biopsies are open procedures. The qualifier X is used to identify the excision as a biopsy. A sentinel node biopsy is done to obtain tissue for pathological examination to determine if disease is present.

13. PROCEDURE: Open resection and removal of the left lobe of the liver due to metastasis from colon carcinoma Character Code Explanation Section 0 Medical and Surgical Body System

F Hepatobiliary System and Pancreas Root Operation

T Resection

Body Part 2 Liver, Left Lobe Approach 0 Open Device Z No Device Qualifier Z No Qualifier

INDEX: Resection, liver, left lobe 0FT2 This procedure is a resection by definition because the entire body part, left lobe of liver, was removed

14. PROCEDURE: Tube Thoracostomy—chest tube insertion by incision—for drainage of malignant pleural effusion from right side of pleural cavity Character Code Explanation Section 0 Medical and Surgical Body System

W Anatomical Regions, General

Root Operation

9 Drainage

Body Part 9 Pleural Cavity, Right Approach 0 Open Device 0 Drainage Device Qualifier Z No Qualifier

INDEX: Thoracostomy tube see Drainage Device, pleural cavity 0W99. The objective of this procedure is to drain fluid to remove the effusion through a drainage device, in this case, the chest tube.

15. PROCEDURE: Rigid Bronchoscopy with YAG laser photoresection for the destruction of lesion in the right main bronchus Character Code Explanation Section 0 Medical and Surgical Body System

B Respiratory System

Root Operation

5 Destruction

Body Part 3 Main Bronchus, Right Approach 8 Via Natural or Artificial Opening Endoscopic Device Z No Device Qualifier Z No Qualifier

INDEX: Destruction, bronchus, main, right 0B53. Laser photoresection is a destruction procedure. Approach is endoscopy by bronchoscopy. A bronchoscopy is involves visualization of the respiratory system by entering through the pharynx or nasopharynx which is a natural opening using an endoscopic device.

18. PROCEDURE: Bone Marrow Needle Extraction Biopsy, Iliac Character Code Explanation Section 0 Medical and Surgical Body System 7 Lymphatic and Hemi Systems Root Operation D Extraction Body Part R Bone Marrow, Iliac Approach 3 Percutaneous Device Z No Device Qualifier X Diagnostic

INDEX: Extraction, Bone Marrow, Iliac, 07DR Bone marrow biopsies are not coded to excisions as there is no cutting but instead involve pulling out tissue from the bone. Therefore, bone marrow biopsies or aspirations are extractions with qualifier of X as these are diagnostic procedures.

19. PROCEDURE: Laparoscopic total splenectomy Character Code Explanation Section 0 Medical and Surgical Body System 7 Lymphatic and Hemic Systems Root Operation T Resection Body Part P Spleen Approach 4 Percutaneous Endoscopic Device Z No Device Qualifier Z No Qualifier

INDEX: Splenectomy, see Excision or Resection, Lymphatic and Hemic Systems, total splenectomy would be Resection, 07T. A laparoscopic approach is a percutaneous endoscopy as the trocars and ports used in a laparoscopic are placed in the body percutaneously so that the device of the laparoscope can be inserted.

20. PROCEDURE: Lymph Node Open Biopsy by Excision, Right Axilla Character Code Explanation Section 0 Medical and Surgical Body System 7 Lymphatic and Hemic Systems Root Operation B Excision Body Part 5 Lymphatic, Right Axillary Approach 0 Open Device Z No Device Qualifier X Diagnostic

INDEX: Biopsy see Excision with Qualifier, Excision, Lymphatic, Axillary, Right 07B

Chapter 7

Endocrine, Nutritional, and Metabolic

Diseases

Review Exercise: Chapter 7

1. Type 2 diabetic with nephropathy due to the diabetes E11.21 Diabetes, type 2, with, nephropathy
2. Toxic diffuse goiter with thyrotoxic storm E05.01 Goiter, toxic—see Hyperthyroidism, with goiter (diffuse), with thyroid storm
3. Cushing’s syndrome E24.9 Syndrome, Cushing's
4. Hypokalemia E87.6 Hypokalemia
5. Cystic fibrosis with pulmonary manifestations E84.0 Fibrosis, cystic, with, pulmonary manifestations
6. Uncontrolled (hyperglycemia) type 2 diabetes mellitus; mild degree malnutrition E11.65 Diabetes, type 2, with, hyperglycemia E44.1 Malnutrition, degree, mild There is no combination code for diabetes and malnutrition, nor is there a stated cause-and- effect relationship between diabetes and malnutrition There are no ICD-10-CM codes that state “uncontrolled” diabetes but instead the uncontrolled status is identified as diabetes with hyperglycemia. Uncontrolled diabetes means the patient has elevated glucose levels. In this example, there is no stated relationship between the diabetes and the malnutrition so the condition is coded separately.
7. Panhypopituitarism E23.0 Panhypopituitarism
8. Lower extremity ulcer on skin of left heel secondary to brittle diabetes mellitus, type 1, uncontrolled E10.621 Diabetes, type 1, with foot ulcer L97.429 Ulcer, heel - see Ulcer, lower limb, heel, left E10.65 Diabetes, type 1, with,

hyperglycemia (uncontrolled)

9. Diabetic proliferative retinopathy in a patient with controlled type 1 diabetes E10.359 Diabetes, with, retinopathy, proliferative
10. Overweight adult with a body mass index (BMI) of 26. E66.3 Overweight Z68.26 Body, mass index, adult, 26.0-
11. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) E22.2 Syndrome, inappropriate secretion of antidiuretic hormone
12. Hypoglycemia in type 1 diabetes with coma E10.641 Diabetes, type 1, with, hypoglycemia, with coma
13. Postsurgical hypothyroidism E89.0 Hypothyroidism, postsurgical
14. Folic acid deficiency E53.8 Deficiency, folic acid
15. Partial androgen insensitivity syndrome E34.52 Syndrome, androgen insensitivity, partial
16. PROCEDURE: Open total thyroidectomy Character Code Explanation Section 0 Medical and Surgical Body System

G Endocrine System

Root Operation

T Resection

Body Part K Thyroid Gland Approach 0 Open Device Z No Device Qualifier Z No Qualifier

INDEX: Thyroidectomy, see Resection, Endocrine System, thyroid gland, 0GTK. Total thyroidectomy is removal of entire thyroid.