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Introduction to ICD-10-CM and ICD-10-PCS,Certain Infectious and Parasitic Diseases,Neoplasms and Diseases of Blood and Blood Forming Organs and Also Excercises with Answer.
Typology: Exercises
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Answer Key
Chapter 1
Introduction to ICD-10-CM
Exercise 1.
Exercise 1.
Exercise 1.
Exercise 1.
Exercise 1.
Exercise 1.
Chapter 2
Introduction to ICD-10-PCS
Review Exercises: Chapter 2
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.
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.
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.
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)
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.
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.
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.
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,
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
occurring in the esophagus and causing an esophagitis condition.
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
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.
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
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.
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
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.
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.
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
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
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.
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
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.
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
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.
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.
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.
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.
INDEX: Biopsy see Excision with Qualifier, Excision, Lymphatic, Axillary, Right 07B
Chapter 7
Endocrine, Nutritional, and Metabolic
Diseases
Review Exercise: Chapter 7
hyperglycemia (uncontrolled)
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.