ICD-10-PCS -Chapter 2 -Guidelines for Medical & Surgery

procedures performed using the open approach with percutaneous endoscopic assistance are coded to what approach

"Open" (the operative site is exposed to the surgeon's eye)

what are the options for coding a procedure done only on a device

Change, irrigation, removal, revision

What is the largest section of the ICD-10-PCS system

Medical & Surgical section

What section are procedures performed on a pregnant female coded to

Medical and Surgical

What section are procedures performed on the products of conception coded to

Obstetrics

if the objective of an embolization procedure is to narrow the lumen of a vessel, what would the root operation be

Restriction

putting in autologous or nonautologous cells is coded to what section instead of Medical and Surgery

Administration section

what is root operation for putting in mature and functioning living body part taken from another individual or animal

Transplantation

what general body part values are available for the Gastrointestinal body system

Upper intestinal tract, lower intestinal tract

how are the coronary arteries classified

as a single body part, further specified by number of arteries treated

how would you code a separate procedure to place a temporary applicator for delivering the brachytherapy

code it to the root operation "Insertion" and the device value "Other Device"

How would you code procedures performed following a delivery or abortion for curettage of the endometrium or evacuation of retained products of conception

code it to the root operation Extraction and the body part ""Products of Conception, Retained", in the Obstetrics section

what should a coder do if an intended procedure is discontinued or not completed, and no other root procedure is performed?

code it to: root operation Inspection of the body part or anatomical region inspected

how do you code when no device remains after a procedure is completed

code the "No Device" value

how would you code a procedure performed using a percutaneous endoscopic approach with incision or extension of an incision to assist in the removal of all or a portion of a body part, or to anastomose a tubular body part to complete the procedure

code the approach "Percutaneous Endoscopic"

if a procedure is performed on a continuous section of a tubular body part, how would you code that

code the body part value that relates to the furthest anatomical site from the point of entry

if more than one Inspection procedure is performed on the same body part during the same episode using a different approach, you would

code the inspection procedure separately

what would you code if an attempt to stop bleeding is unsuccessful

code the more definitive root operation, not control. Ex - resection of spleen to stop bleeding would be coded as resection, not control

in cardiovascular body systems, how would you code if a general body part is available in the correct root operation table, and coding to the closest branch would mean assigning a code to a different body system

code the procedure to the general body part value

how would you code a portion of the body that doesn't have a separate body part value

code the value for the whole body part

regarding root operations, what does not get coded?

components or explanations that are mentioned in the root operation are not coded, and procedure steps to reach operative site, close operative site, even anastomosis is not coded

define other repairs

control, repair

In limited root operations, there is a Device classification of "Temporary" and "Intraoperative". When would they be used

in certain procedures where the devices are clinically significant, where the purpose of the device is to be utilized for a brief duration during a procedure or current inpatient stay

where can you find the appropriate body part to reference

in the Index entry or the body part key

where would you code diagnostic and therapeutic dilation and curettage performed during times other than postpartum or postabortion

in the Medical and Surgery section, to the root operation Extraction and the body part Endometrium

always involve a devic

insertion, removal, revision, change, replacement, supplement

involve examination only

inspection, map

if spinal joints are immobile from a spinal fusion procedure, how would this be coded

it is classified by the level of the spine. single vertebral joints and multiple vertebral joints have distinct body part values at each spinal level. ???

if a radioactive brachytherapy source is left in the body at the end of the procedure, how do you handle that

it is coded separately to the root operation "Insertion" with the device value "Radioactive Element"

if a procedure on toes is performed and there isn't a separate body part value for toes, how would you code it

it would be coded to the body part value for the foot

how would you code a procedure performed on the fingers if there isn't a separate body part value for fingers

it would be coded to the body part value for the hand

if the reposition procedure also included a cast or splint would that get coded separately

no

if a sample is sent to pathology, does that constitute a biopsy

no, most body parts and substances are sent to pathology

are sutures, ligatures, radiological markers, and temporary postoperative wound drains coded as devices

no, they are integral to the performance of the procedure

When "Inspection" is an integral part of a procedure to achieve an objective, would that be coded separately?

no.

if the objective of an embolization procedure is to completely close a vessel, what would the root operation be

occlusion

when can a device be coded

only if it remains after a procedure is completed.

which approach would you choose if surgeon can visualize site where the procedure is to be performed

open

the root operation "Transfer" contains qualifiers that specify what

qualifiers that can be used to describe other tissue layers involved if there is more than one tissue layer involved

which section would you code brachytherapy to

radiation therapy section

what root operation would you assign if the only objective to the procedure was freeing a body part without any cutting

release

what root operation would you assign to a reduction of a displace fracture

reposition

PCS contains specific body parts for anatomical subdivisions of a body part. when all of a particular subdivision of a body part is removed, would you code that as excision or resection

resection

what is the difference between excision and resection

resection - the removal of an entire body part excision - the removal of a portion of a body part

alter the diameter /route of a tubular body part

restriction, occlusion, dilation, bypass

which section codes fully represent the specific procedure described in the code title and don't need additional codes from other sections

section X

how should a coder code overlapping layers of the musculoskeletal system in a procedure, given that there are different body part values for each layer

select the body part with the deepest layer

what is correct sequence if a diagnostic procedure was performed for the principal diagnosis and a procedure is performed for definitive treatment of secondary diagnosis

sequence diagnostic procedure as principal procedure, since the procedure most relate to the principal diagnosis takes precedence

what is the correct sequence of procedure performed for definitive treatment and diagnostic procedures performed for both principal diagnosis and secondary diagnosis

sequence procedure performed for definitive treatment most related to principal diagnosis as principal procedure

what if no procedures were performed that are related to principal diagnosis, but procedures were performed for definitive treatment and diagnostic procedures were performed for secondary diagnosis

sequence procedure performed for definitive treatment of secondary diagnosis as principal procedure since there are no procedures related to the principal diagnosis

what is the correct sequence of procedure performed for definitive treatment of both principal diagnosis and secondary diagnosis

sequence the procedure performed for definitive treatment most related to principal diagnosis as principal procedure

what does the root operation "Control" mean

stopping, attempting to stop, postprocedural or other acute bleeding

what tool can you use in helping to decide what approach to code

the approach decision tree

During "Inspection" what would the most distal body part be?

the body part that is the furthest away from the starting point of the inspection

In a procedure involving many tissue layers of the skin, subcutaneous tissue, fascia, or muscle, what would you code the procedure to

the body part value that is the deepest tissue

how would you code an instance of a device intending to remain after the procedure completion, but the device requires removal before operative episode in which it was inserted (complication, inadequate size)

the coder needs to code both the Insertion and the Removal of the device

what should the coder do if a diagnostic procedure (biopsy) is followed by a more definitive procedure at the same procedure site

the coder should code the biopsy and the more definitive treatment

what is designated as the upper intestinal tract

the esophagus down to and including the duodenum

How do you determine the appropriate root operation

the full definition of the root operation from the PCS Tables must be applied

In order for a procedure to be coded a biopsy, what does the intent need to be?

the intent must be to analyze the tissue, fluid, and gases that are excised, extracted, or drained. The intent must be diagnostic. if biopsy, seventh character "X", diagnostic.

what is designated as the lower intestinal tract

the jejunum down to and including the rectum and anus

what body part value is being coded in the root operation "Release"

the part being freed is coded, not the tissue being manipulated or cut to free the body part

how would you code procedures performed on tendons, ligaments, bursae, and fascia that are supporting a joint

the procedure is coded to the body part in the body system that is the focus of the procedure

Besides the root operation, biopsies are coded with

the qualifier Diagnositic

how would you code procedures performed on joint structures

the would be coded to the body part in the Joint Body Systems

what should you remember about coding coronary bypass procedures and noncoronary bypass procedures

they are handled differently.

how would you code a procedure that was only performed on a device, no body parts

they would be coded to the procedure performed

if identical procedures are performed bilaterally, how would you code it

use one code if there is a bilateral code, use 2 codes for each procedure if there isn't one available

when the same procedure is performed using the same device and qualifier values regarding coronary arteries is reported, how would you code this

use one procedure code that specifies multiple arteries

what do you consider first when deciding on the appropriate "approach"

whether or not there was an incision through the skin or mucous membranes

how would you code procedures performed percutaneously via a device placed for the procedure

you code to the approach " Percutaneous"

how would you code a procedure performed indirectly by application of external force through intervening body layers

you code to the approach "External"

you would need to code both procedures if an excision or resection of a body part is followed by a replacement procedure except in this case -

you don't code 2 procedures if the excision or resection is considered integral or preparatory for the replacement procedure

how would you code a separate procedure to put in a drainage device

you would code it to the root operation "Drainage" with the device value "Drainage Value"

if multiple non-tubular body parts in a region are inspected, how would you code

you would code the body part specifying the entire area inspected

if multiple tubular parts are inspected, how would you code this

you would code the most distal body part

if "peri" is combined with a body part to identify the site, and the site is not further specified, where would you code the procedure to

you would code the procedure to the body part named when a more specific value is not available

how would you code a procedure performed within an orifice on structures visible without any aid of instrumentation

you would code to the approach "External"

how do you code bypass procedures

you would identify the body part bypassed "from" which would be the 4th character in the code. you would then identify the body part bypassed "to", which would be the qualifier(7th character)

when an excision is performed for harvesting an autograph, there may be 2 codes. explain

you would need a separate procedure to code if it is harvested from a separate operative site, unless the Table in the 7th character qualifier specifies the site from which it was obtained.

In the Medical and Surgery section, which character refers to the root operation

3rd

how do you code when a combination of devices are used on the same vertebral joint

-if interbody fusion device is used to render the joint immovable, code as "interbody Fusion Device" -if the bone graft is the only device used to render the joint immobile, code procedure as "Nonautologous Tissue Substitute". -if mixture of autologous and nonautologous bone graft is used to render the joint immobile, code device as "Autologous Tissue Substitute".

when would a coder code multiple procedures in the same operative episode

-the same root operation is performed on different body parts as defined by the distinct values of body part character -same root operation is repeated in multiple body parts, and the body parts are separate and distinct body parts classified to a single body part value -multiple root operations with distinct objectives are performed on same body part -the intended root operation is attempted using one approach, but is converted to another approach

In the Medical and Surgery section, which character in the code refers to the Body System

2nd

how should a coder code a coronary bypass when multiple arteries are bypassed

code a separate procedure for each artery that uses a different device and/or qualifier

what should a coder do if an intended procedure is discontinued and not completed and another root operation is done in its place?

code it the root procedure that was performed

if a specific branch of a body part does not have its own value, how would you code it

code it to the closest branch that has a value

what is the key component to building ICD-10-PCS codes

determining the root operation or intent of the procedure

what root operation would you assign if the sole objective of the procedure was to separate or transect a body part

division

involving cutting or separation only

division, release, transplantation, reattachment, transfer, reposition

take out solids/fluids/gases from a body part

drainage, extirpation, fragmentation

how would you code a case where multiple joints are fused?

each would be coded as a separate procedure if using a different device and/or qualifier

what are the three root operation choices that you can choose from when coding biopsies

excision, extraction, and drainage

Take out some or all of a body body part (list root operations)

excision, resection, detachment, destruction, extraction

what is considered the products of conception

fetus, placenta, amniotic sac, amniotic fluid, and umbilical cord

define other objectives

fusion, alteration, creation

how should the coder code a coronary bypass procedure

identify the number coronary arteries bypass "to", which is the 4th character. Next, identify where the vessel bypassed "from" or "originated", which would be qualifier (7th character)

When can you code general anatomic regions

if the body part is not specified, or when the procedure is not confined to one specific body system.

when coming upon choices of upper and lower body parts, how would you know what to choose

if the location is above the diaphragm it is upper, if the location is below the diaphragm it is lower.