Final Quiz 5.2 (ICD-10-PCS)
In ICD-10-PCS, a 1-year-old child was left in a car for 5 hours during a blizzard with extreme drop in temperature. In the hospital, hyperthermia is used to raise the child's body temperature back to normal. One session was completed.
6A3Z0ZZ NOTE: Extracorporeal or Systemic Therapies Section = 6 Body System = Physiological System = A Root operation = Hyperthermia = 3 Body system = None = Z Duration = Single = 0 Qualifier = No Qualifier = Z Qualifier = No Qualifier = Z
In ICD-10-PCS, incision and drainage external perianal abscess
0D9QXZZ NOTE: Medical and Surgical Section = 0 Body System = Gastrointestinal System = D Root operation = Drainage = 9 Body part = Anus = Q Approach = External = X Device = No Device = Z Qualifier = No Qualifier = Z
In ICD-10-PCS, colonoscopy with sigmoid colon polypectomy
0DBN8ZZ NOTE: Medical and Surgical Section = 0 Body System = Gastrointestinal System = D Root operation = Excision = B (The colonoscopy [inspection] is included in the excision of the polyps.) Body part = Sigmoid Colon = N (This is from where the polyp was excised.) Approach = Via Natural or Artificial Opening Endoscopic = 8 Device = No Device = Z Qualifier = No Qualifier = Z
In ICD-10-PCS, open left neck total lymphadenectomy
0DBN8ZZ NOTE: Medical and Surgical Section = 0 Body System = Lymphatic and Hemic Systems = 7 Root operation = Resection = T (because the surgical removal was the total lymph nodes) Body part = Lymphatic, Left Neck = 2 Approach = Open = 0 Device = No Device = Z Qualifier = No Qualifier = Z
In ICD-10-PCS, percutaneous transposition left radial nerve
01S63ZZ NOTE: Medical and Surgical Section = 0 Body System = Peripheral Nervous System = 1 Root operation = Reposition = S Body part = Radial Nerve = 6 Approach = Percutaneous = 3 Device = No Device = Z Qualifier = No Qualifier = Z
In ICD-10-PCS, heart transplant using porcine heart, open
02YA0Z2 NOTE: Medical and Surgical Section = 0 Body System = Heart and Great Vessels = 2 Root operation = Transplantation = Y Body part = Heart = A Approach = Open = O Device = No Device = Z Qualifier = Neoplastic = 2 (Porcine heart)
In ICD-10-PCS, percutaneous endoscopic clipping cerebral aneurysm
03VG4CZ NOTE: Medical and Surgical Section = 0 Body System = Upper Arteries = 3 Root operation = Restriction = V (The clip will isolate the aneurysm from the artery.) Body part = Intracranial artery = G Approach = Percutaneous endoscopic = 4 Device = Extraluminal device = C (The "clip" is the device.) Qualifier = No Qualifier = Z
In ICD-10-PCS, percutaneous embolization left uterine artery using coils
04LF3DU NOTE: Medical and Surgical Section = 0 Body System = Lower Arteries = 4 (Uterine artery is below the diaphragm.) Root operation = Occlusion = L (The coil isolates the embolus from floating through the artery.) Body part = Internal Iliac Artery, Left = F (Uterine Artery) Approach = Percutaneous = 3 Device = Intraluminal Device = D (Intraluminal means inside the tubular or lumina.) Qualifier = Uterine Artery = U
In ICD-10-PCS, percutaneous insertion Greenfield IVC filter
06H03DZ NOTE: Medical and Surgical Section = 0 Body System = Lower Veins = 6 Root operation = Insertion = H Body part = Inferior vena cava = 0 (IVC = Inferior vena cava) Approach = Percutaneous = 3 Device = Intraluminal Device = D (Intraluminal = within a lumen or tubular body part) Qualifier = No Qualifier = Z
In ICD-10-PCS, removal FB left cornea
08C9XZZ NOTE: Medical and Surgical Section = 0 Body System = Eye = 8 Root operation = Extirpation = C (taking out the foreign body—solid matter) Body part = Cornea, Left = 9 Approach = External = X Device = No Device = Z Qualifier = No Qualifier = Z
In ICD-10-PCS, reattachment severed left ear
09M1XZZ NOTE: Medical and Surgical Section = 0 Body System = Ear, Nose, Sinus = 9 Root operation = Reattachment = M Body part = External Ear, Left = 1 Approach = External = X Device = No Device = Z Qualifier = No Qualifier = Z
In ICD-10-PCS, percutaneous radiofrequency ablation of the left vocal cord
0C5V3ZZ NOTE: Medical and Surgical Section = 0 Body System = Mouth and Throat = C Root operation = Destruction = 5 (Ablation is destruction.) Body part = Vocal Cord, Left = V Approach = Percutaneous = 3 Device = No Device = Z Qualifier = No Qualifier = Z
In ICD-10-PCS, excision malignant lesion outer upper lip
0CB0XZZ NOTE: Medical and Surgical Section = 0 Body System = Mouth and Throat = C Root operation = Excision = B Body part = Upper Lip = 0 Approach = External = X Device = No Device = Z Qualifier = No Qualifier = Z
In ICD-10-PCS, laparoscopic appendectomy
0DTJ4ZZ NOTE: Medical and Surgical Section = 0 Body System = Gastrointestinal System = D Root operation = Resection = T (The entire organ [appendix] was surgically removed.) Body part = Appendix = J Approach = Percutaneous Endoscopic = 4 (laparoscopic) Device = No Device = Z Qualifier = No Qualifier = Z
In ICD-10-PCS, report the excision malignant lesion skin of left ear.
0HB3XZZ NOTE: Medical and Surgical Section = 0 Body System = Skin and Breast = H Root operation = Excision = B Body part = Skin, Left Ear = 3 Approach = External = X Device = No Device = Z Qualifier = No Qualifier = Z (NOTE: If this were a diagnostic procedure, they would not already know the lesion is malignant.)
In ICD-10-PCS, nonexcisional debridement left heel ulcer
0HDNXZZ NOTE: Medical and Surgical Section = 0 Body System = Skin and Breast = H Root operation = Extraction = D (stripping off the tissue, etc.) Body part = Skin, Left Foot = N Approach = External = X Device = No Device = Z Qualifier = No Qualifier = Z
In ICD-10-PCS, a percutaneous fascia transfer to cover defect of the right anterior neck
0JX43ZZ NOTE: Medical and Surgical Section = 0 Body System = Subcutaneous Tissue and Fascia = J Root operation = Transfer = X Body part = Subcutaneous Tissue and Fascia, Right Neck = 4 Approach = Percutaneous = 3 Device = No Device - Z Qualifier = No Qualifier = Z
In ICD-10-PCS, right TRAM pedicle flap reconstruction status post mastectomy, muscle only open
0KXK0Z6 NOTE: TRAM = Transverse Rectus Abdominis Myocutaneous Medical and Surgical Section = 0 Body System = Muscles = K Root operation = Transfer = X Body part = Abdomen Muscle, Right = K (Rectus abdominis muscle) Approach = Open = 0 Device = No Device = Z Qualifier = Transverse Rectus Abdominis Myocutaneous Flap = 6
In ICD-10-PCS, open reduction fracture left tibia
0QSH0ZZ NOTE: Medical and Surgical Section = 0 Body System = Lower Bones = Q Root operation = Reposition = S Body part = Tibia, Left = H Approach = Open = 0 Device = No Device = Z Qualifier = No Qualifier = Z
In ICD-10-PCS, routine insertion of indwelling Foley catheter
0T9B70Z NOTE: Medical and Surgical Section = 0 Body System = Urinary system = T Root operation = Drainage = 9 Body part = Bladder = B Approach = Via Natural or Artificial Opening = 7 Device = Drainage device = 0 Qualifier = No Qualifier = Z
In ICD-10-PCS, transurethral cystoscopy with removal of right ureteral calculus
0TC68ZZ NOTE: Medical and Surgical Section = 0 Body System = Urinary system = T Root operation = Extirpation = C (the removal of the calculus) Body part = Ureter, Right = 6 Approach = Via Natural or Artifical Opening Endoscopic = 8 Device = No Device = Z Qualifier = No Qualifier = Z
In ICD-10-PCS, laparotomy with exploration and adhesiolysis of the left ureter
0TN70ZZ NOTE: Medical and Surgical Section = 0 Body System = Urinary System = T Root operation = Release = N (Adhesiolysis is the cutting of adhesions.) Body part = Ureter, Left = 7 Approach = Open = 0 Device = No Device = Z Qualifier = No Qualifier = Z
In ICD-10-PCS, laparoscopy with bilateral occlusion fallopian tubes using external clips
0UL74CZ NOTE: Medical and Surgical Section = 0 Body System = Female Reproductive System = U Root operation = Occlusion = L Body part = Fallopian Tubes, Bilateral = 7 Approach = Percutaneous Endoscopic = 4 Device = Extraluminal Device = C (external clips) Qualifier = No Qualifier = Z
In ICD-10-PCS, facelift, open
0W020ZZ NOTE: Medical and Surgical Section = 0 Body System = Anatomical Regions, General = W Root operation = Alteration = 0 Body part = Face = 2 Approach = Open = 0 Device = No Device = Z Qualifier = No Qualifier = Z
In ICD-10-PCS, thoracentesis right pleural effusion
0W993ZZ NOTE: Medical and Surgical Section = 0 Body System = Anatomical Regions, General = W Root operation = Drainage = 9 Body part = Pleural Cavity, Right = 9 Approach = Percutaneous = 3 Device = No Device = Z Qualifier = No Qualifier = Z
In ICD-10-PCS, percutaneous chest tube placement left pneumothorax
0W9B30Z NOTE: Medical and Surgical Section = 0 Body System = Anatomical Regions, General = W Root operation = Drainage = 9 Body part = Pleural Cavity, Left = B Approach = Percutaneous = 3 Device = Drainage Device = 0 Qualifier = No Qualifier = Z
In ICD-10-PCS, administration of Oxazolidinone, inhaled through the nose
3E09728 NOTE: Administration Section = 3 Body System = Physiological Systems and Anatomical Regions = E Root operation = Introduction = 0 Body part = Nose = 9 (inhaled through the nose) Approach = Via Natural or Artificial Opening = 7 Device = Anti-infective = 2 Qualifier = Oxazolidinones = 8
Elaine was a diabetic and had a wound that would not heal, so Dr. Smith had her placed in a hyperbaric oxygenation of the wound. The root operation term used in ICD-10-PCS is:
Assistance: taking over a portion of a physiological function by extracorporeal means NOTE: RATIONALE: Hyperbaric oxygenation encourages and helps (assists) the wound tissues to heal.
In ICD-10-PCS, patient admitted after experiencing seizure. CT of brain, high osmolar contrast taken with and without contrast
B02000Z NOTE: Imaging Section = B Body System = Central Nervous System = 0 Root operation = Computerized Tomography (CT Scan) = 2 Body part = Brain = 0 Contrast = High Osmolar = 0 Qualifier = Unenhanced and Enhanced = 0 Qualifier = None = Z
In ICD-10-PCS, a PET imaging of the myocardium using Rubidium 82
C23GQZZ NOTE: Nuclear Medicine Section = C Body System = Heart = 2 Root operation = Positron Emission Tomographic (PET) Imaging = 3 Body part = Myocardium = G Radionuclide = Rubidium 82 (Rb-82) = Q Qualifier = None = Z Qualifier = None = Z
In ICD-10-PCS, beam radiation was administered using electrons for a femoral bone tumor.
DP093ZZ NOTE: Radiation Therapy Section = D Body System = Musculoskeletal System = P Root operation = Beam Radiation = 0 Treatment Site = Femur = 9 Modality Qualifier = Electrons = 3 Isotope = None = Z Qualifier = None = Z
The baby was having trouble passing through the vaginal canal, so Dr. Jones use forceps to help him along. Baby Boy was born at 12:57 pm. The root operation term used for this ICD-10-PCS code is:
Extraction: pulling or stripping out or off all or a portion of a body part by the use of force NOTE: RATIONALE: The physician used the forceps to help the baby out of the birth canal, extracting the baby from the wound. Therefore, extraction is the correct root operation.
In ICD-10-PCS, patient admitted into Behavioral Health Hospital for neuropsychological testing
GZ13ZZZ NOTE: Mental Health Section = G Body System = None = Z Root operation = Psychological Tests = 1 Type Qualifier = Neuropsychological = 3 Qualifier = None = Z Qualifier = None = Z Qualifier = None = Z
Dr. Smith performed an appendectomy on Douglas Doe. This is reported from the ______ Body System character of the ICD-10-PCS code.
Gastrointestinal System NOTE: RATIONALE: The appendix is a component of the gastrointestinal system.
In the Medical Surgical Section of ICD-10-PCS, the fourth character position represents which of the following?
body part NOTE: Character 1 = Section Character 2 = Body System Character 3 = Root Operation Character 4 = Body Part Character 5 = Approach Character 6 = Device Character 7 = Qualifier
Identify the correct root operation, in ICD-10-PCS, for the following: Colon polyp fulguration
destruction NOTE: Fulguration means "to destroy." ICD-10-PCS uses the direct term "destruction."
Identify the correct root operation, used in ICD-10-PCS, for the following: Amputation first left toe
detachment NOTE: Amputation means the removal of an upper or lower extremity by trauma, surgery, or disease. In ICD-10-PCS, the root operation term is more specific and technical, using the term "detachment."
Identify the correct root operation, used in ICD-10-PCS, for the following: Excision descending colon
excision NOTE: When only a part of an organ has been surgically removed, the root operation term "excision" is used. Remember that the descending colon is only one part of the entire large colon.
Identify the correct root operation for the following: Uterine dilation and curettage
extraction NOTE: Curettage is the scraping of a body cavity, such as the uterus, to excavate. This is reported as extraction in ICD-10-PCS. The dilation is not separately reported as it is an integral part of the procedure.
Identify the correct root operation term used in ICD-10-PCS for the following: Cesarean section on 27-year-old woman at 38 weeks
extraction NOTE: The term "delivery" is only used when the birthing process gets little to no assistance as the neonate passing through the vaginal canal. A C-section is performed to extract the products of conception from the mother.
Identify the correct root operation term used in ICD-10-PCS for the following: Lithotripsy left ureter with removal of fragment
fragmentation; extirpation NOTE: Lithotripsy is the breaking up of a stone within the body, which would be reported with the ICD-10-PCS root operation term "fragmentation." Then, you must complete the story, reporting the removal of the fragment (fragment of the broken stone) reported with the ICD-10-PCS term "extirpation." Remember, in ICD-10-PCS the term "removal" is only used when a device is taken out.
Identify the correct root operation term used in ICD-10-PCS for the following: Spinal fusion cervical C1-C2
fusion NOTE: The term "fusion" is also used in ICD-10-PCS.
Identify the correct root operation term used in ICD-10-PCS for the following: Placement of single-lead cardiac pacemaker
insertion NOTE: The pacemaker (a device) is inserted into the body; therefore, "insertion" is the correct root operation term for ICD-10-PCS.
Identify the correct root operation, used in ICD-10-PCS, for the following: Cystoscopy
inspection NOTE: Remember, in medical terminology, the suffix -oscopy means to view. In ICD-10-PCS, the "viewing" is done to "inspect" the organ or body part. Therefore, the root operation term is "inspection."
Identify the correct approach term used in ICD-10-PCS for the following: Laparoscopic cholecysectomy
percutaneous endoscopic NOTE: Laparoscopic surgery uses small cuts through the skin (percutaneous) through which an endoscope is passed into the body.
Identify the correct root operation term used in ICD-10-PCS for the following: Removal of cardiac pacemaker
removal NOTE: In ICD-10-PCS, the root operation term "removal" is only used to report the taking out a device from the body. A pacemaker is a device.
A complete redo of a knee replacement requiring a new prosthesis is coded to which root operation(s)?
removal; replacement NOTE: See the ICD-10-PCS Official Guidelines for Coding and Reporting 2018, B3.2 Multiple Procedures, and B3.2c. Multiple root operations with distinct objectives are performed on the same body part.
Identify the correct root operation term used in ICD-10-PCS for the following: Mitral valve ring annuloplasty, open
repair NOTE: An annuloplasty is a reconstructive procedure performed to narrow the opening of a leaking cardiac valve with the intention of reducing the link, thereby repairing it.
Identify the correct root operation, used in ICD-10-PCS, for the following: Total left knee replacement
replacement NOTE: A replacement is a replacement in ICD-10-PCS, too!
Identify the correct root operation term used in ICD-10-PCS for the following: Angioplasty of the right common iliac artery accomplished with an autologous tissue substitute
replacement NOTE: This angioplasty (repair of the artery) included a graft, meaning a portion of the artery was replaced. Therefore, in ICD-10-PCS, this is reported as a "replacement."