CCS PREP EXAM Section 1 Conventions, General coding guidelines and chapt spec guidelines
Which of the following organizations developed ICD-10-PCS? A. World Health Organization B. AHIMA C. 3M under contract to the Centers for Medicare & Medicaid Services D. National Center for Health Statistics
3M under contract to the Centers for Medicare & Medicaid Services
If a patient with documented history of HIV disease is currently managed on antiretroviral meds...
Assign B20 with Z79.899 other long term(current) drug therapy to identify antiretroviral medication.
What does the second character represent in the ICD-10-PCS code structure in the Medical and Surgical Section? A. Section B. Body system C. Root operation D. Body part
Body system
A 67-year-old male was found by his family in an altered state. He has a 50-year history of seizure disorder, so paramedics were called to the home where they witnessed a grand mal seizure. The patient's family tells doctors that he has acute bronchitis and has been poorly compliant with his antiepileptic medications. Patient is admitted in a nonresponsive and lethargic state. CT of head is negative for significant acute pathology. Final diagnoses: (1) Postictal state following grand mal seizure, (2) epilepsy, (3) acute bronchitis, (4) CT of head. Assign the appropriate codes.
Codes: G40.409, J20.9, Z91.14, BW28ZZZ Comments: (1) Category G40 is assigned for seizures that the physician documents are due to epilepsy. Reference: ICD-10-CM Coding Handbook, 2014 Revised Edition, p. 206.
A patient undergoing hemodialysis for renal disease in the outpatient unit of a hospital develops what is believed to be heartburn. After a few hours of observation, he is admitted to the hospital for further care. The consulting cardiologist diagnoses this patient's condition as unstable angina. What is the principal diagnosis for the hospital stay? A. Complication of dialysis B. Heartburn C. Renal disease D. Unstable angina
D. Unstable angina
When the type of congenital anomaly is specified, but no specific code is provided, what should the coder do? A.Assign the code for other specified anomaly of that type and site. B.Assign additional codes for manifestations of the anomaly. C.Query the physician for instructions. D.A and B
D.A and B
Secondary diabetes may be due to: A.Drug or chemical B.Infection C.Removal of pancreas D.All of the above
D.All of the above
The patient was admitted for epistaxis and coagulopathy due to therapeutic anticoagulation medication for atrial fibrillation. There is recent history of resection of a mass of the vestibule of the mouth with graft repair and radiation therapy. When seen in the physician office, the patient's Coumadin was discontinued due to high protime. Although the Coumadin was stopped, the pro-time continued to rise. Protime corrected with frozen plasma during hospitalization. Final diagnoses: (1) Epistaxis secondary to Coumadin, (2) recurrent cancer of vestibule of the mouth, (3) atrial fibrillation, (4) transfusion non-autologous plasma through peripheral vein. Assign the appropriate codes.
Codes: D68.32, R04.0, T45.515A, C06.1, I48.91, Z79.01, 30233K1 Comments: (1) The principal diagnosis is D68.32 (see Coding Clinic. D68.318 is not appropriate for patients on anticoagulant therapy. The circumstances of the admit will determine principal dx. In this case, the epistaxis is an adverse effect that resulted in "coagulopathy" and listed first. R04.0 will be used as an additional diagnosis per Coding Clinic. (2) Code T45.515A is assigned for the adverse effect of the anticoagulant. References: ICD-10-CM Coding Handbook, 2014 Revised Edition, pp. 197-198, and Coding Clinic, 1st Quarter, 2016 page 14..
An elderly female patient was taken to the emergency medicine department by his family when she became unusually agitated and aggressive. MRI of the brain showed no evidence of infarct, hemorrhage, lesion, or significant abnormality. Infectious workup was also negative. Antibiotic therapy was started with slow improvement in mental status. Antithyroid peroxidase antibodies were positive. Final diagnoses: (1) Altered mental status due to Hashimoto's encephalopathy, (2) MRI brain. Assign the appropriate codes
Codes: E06.3, G93.49, B030ZZZ Comments: (1) Code R41.82, Altered mental status, unspecified, is not assigned when the cause of the change in mental status is known. The condition, in this case Hashimoto's encephalopathy, is coded. (2) Since the encephalopathy is documented by the provider to be secondary to Hashimoto's disease, code G93.49. References: ICD-10-CM Coding Handbook, 2021 Revised Edition,
A 47-year-old male was seen in the emergency room with complaints of nausea, vomiting, diarrhea, and cramping. The patient is a known diabetic whose diabetes is secondary to history of blunt trauma to the pancreas. Blood sugar levels on admission were greater than 600. Final diagnoses: (1) Secondary diabetic ketoacidosis, (2) diabetes mellitus secondary to history of blunt trauma to the pancreas. Assign the appropriate codes.
Codes: E13.10, S36.209S Comments: (1) Codes from category E10-E11 are not assigned for secondary diabetes. Secondary diabetes is coded with category E13. (2) The seventh character S is assigned to code S36.209 for the injury to the pancreas that precipitated the diabetes mellitus, the sequela. Reference: ICD-10-CM Coding Handbook, 2014 Revised Edition, pp. 161-162 and pp. 472-473.
A type II diabetic patient on long term insulin and metformin was admitted because of nephrotic syndrome. Renal biopsy of the left kidney found amyloid deposition but was negative for diabetic nephropathy. Rapid deterioration in renal function, sudden increase in proteinuria, and the absence of diabetic retinopathy also ruled out diabetic nephropathy. Final diagnoses: (1) Glomerulonephritis with nephrotic syndrome due to amyloidosis, (2) type II diabetes mellitus, (3) percutaneous biopsy kidney. Assign the appropriate codes.
Codes: E85.4, N08, E11.9, Z79.4, Z79.84, 0TB13ZX Comments: (1) In this example, the nephropathy is related to amyloidosis and is not a complication of the diabetes mellitus. The underlying condition, the amyloidosis, is sequenced as principal diagnosis, and the manifestation, the nephrosis, is coded as an additional diagnosis. (2) Since there is no cause and effect between diabetes and glomerulonephritis, code E11.9 is assigned for diabetes with no associated complication. Reference: ICD-10-CM Coding Handbook, 2014 Revised Edition, p. 163
The patient has generalized pain and tingling across the arms, legs, chest, back, and abdomen. EKG showed normal sinus rhythm, but she was found to have elevated potassium of 7.3, which was treated urgently with standard therapies. There was resolution of pain after corrected potassium levels and dialysis over 3 days of intermittent dialysis. Final diagnoses: (1) Hyperkalemia due to missed regularly scheduled dialysis appointment, (2) end-stage renal disease secondary to rapidly progressive glomerulonephritis, (3) 3 hemodialysis sessions. Assign the appropriate codes.
Codes: E87.5, N18.6, N01.9, Z91.15, Z99.2, 5A1D70Z, 5A1D70Z, 5A1D70Z Comments: (1) Hyperkalemia is sequenced as principal diagnosis, the condition that was responsible for the admission. (2) Code Z91.15 is assigned for noncompliance with the dialysis regimen. Maintenance on dialysis is included in the code; however, code Z99.2 may be assigned as an additional code as indicated at code N18.6. (3) Facilities may choose to capture hemodialysis that is performed daily by assigning code 5A1D70Z five times, if desired. References: Coding Clinic, Fourth Quarter 2017, pp. 71-73, Coding Clinic, Third Quarter 2007, p. 11 and Coding Clinic, Fourth Quarter 2006, p. 136
Patient was diagnosed with a left humeral fracture when she fell after tripping over a rug at home. The arm was placed in a sling until reduction with internal fixation could be performed at a later date, and the patient was given medication for control of pain. The patient was seen the next day because the pain was not well controlled. No recent or remote tobacco, alcohol, or illicit drug use was documented. Patient is currently being admitted for acute pain control protocol. Final diagnoses: (1) Admit due to poor pain control, (2) fracture of the humerus, (3) hypertension, (4) NIDDM. Assign the appropriate codes.
Codes: G89.11, S42.302A, I10, E11.9, W18.09xA Comments: (1) Assign code G89.11 as principal diagnosis. When pain control or pain management is the reason for the admission/encounter, the category G89 code is listed as principal diagnosis. The underlying cause of the pain should be reported as an additional diagnosis. (2) The seventh character A is assigned for as long as the patient is receiving active treatment for the fracture. Reference: ICD-10-CM Coding Handbook, 2014 Revised Edition, p. 210, and pp. 481-484.
The patient has uncontrolled intraocular pressures that are as high as the mid 30s due to severe stage primary open angle glaucoma (POAG). Surgery was performed to better control pressure through Baerveldt glaucoma implant placement into the right anterior chamber. Final diagnosis: Baerveldt drainage device to right eye due to POAG. Assign the appropriate codes.
Codes: H40.1113, 08123J4 Comments: (1) Code H40.051 for increased intraocular pressure is not assigned because a definitive condition has been diagnosed by the physician and increased pressure is inherent to primary angle-closure glaucoma. The seventh digit identifies the stage of glaucoma. Procedure code 08123J4 would be most appropriate for this procedure as the Baeveldt shunt is an acqueous device specific to drainage procedures using a shunt to drain via catheter. Reference: Coding Clinic, 1st Quarter, 2019 page 27-28.
A patient was admitted with methicillin resistant Staphylococcus aureus (MRSA) cellulitis and abscess of the left thigh due to continuous self-prescribed steroid injections. Patient treated with intravenous antibiotics and excisional debridement. Final diagnoses: (1) Cellulitis and abscess of the thigh due to contaminated needle, (2) self-prescribed steroid abuse, (3) MRSA, (4) excisional debridement skin and fascia. Assign the appropriate codes.
Codes: L03.116, L02.416, B95.62, F55.3, W46.1xxA, 0JBM0ZZ Comments: (1) When a patient is admitted for treatment of a physical complaint that is related to substance use, the physical condition is sequenced first, followed by the code for the abuse or dependence. References: ICD-10-CM Coding Handbook, 2014 Revised Edition, p. 182, and Coding Clinic, Second Quarter 2006, p. 7.
ER note: pelvic pain, positive Beta HCG, and positive Chandelier's sign with vaginal bleeding. Diagnosis consistent with ectopic pregnancy. Patient was admitted and agreed to proceed with left salpingectomy and removal of tubal pregnancy. Two additional cystic lesions made up a large part of the ovary. When they were excised, the small segment of the remaining left ovary was judged to be unsuitable due to endometriosis, so a left oophorectomy was performed en toto. Final diagnoses: (1) Ruptured left tubal ectopic pregnancy, (2) left ovarian follicular cysts, (3) Left ovarian endometriosis, (4) laparoscopic removal of left tubal pregnancy and left ovary cystectomy was performed. Assign the appropriate codes.
Codes: O00.102, N83.02, N80.1, 10T24ZZ, 0UT64ZZ, 0UT14ZZ, Comments: (1) The cyst and endometriosis are not reported with Chapter 15 codes since these conditions are not complications of a viable pregnancy. (2) Codes 10T24ZZ and 0UT64ZZ are assigned for the removal of tubal pregnancy with total removal of the tube. (3) Code 0UT14ZZ is assigned for removal of the left ovary due to cysts and endometriosis. Reference: ICD-10-CM and ICD-10-PCS Coding Handbook, 2013 Revised Edition, pp. 349-350
A 34-year old female at 24 weeks gestation was seen in follow-up due to findings of glycosuria. Her fasting venous plasma glucose is 143 mg/dl. Given this finding, the diagnosis of gestational diabetes mellitus is established. Family history reveals that both parents have diabetes mellitus. The patient was started on both dietary and insulin therapy. Final diagnoses: (1) Gestational diabetes mellitus, (2) pregnancy, (3) insulin maintenance, (4) family history of diabetes mellitus. Assign the appropriate codes.
Codes: O24.414, Z83.3, Z3A.24 Comments: (1) Codes for gestational diabetes are in subcategory O24.4. Only the code for insulin-controlled diabetes is required when the patient is treated with both diet and insulin. Reference: ICD-10-CM Coding Handbook, 2014 Revised Edition, p. 165.
A pregnant patient presents to the hospital at over 40 weeks gestation in active labor. Artificial rupture of the fetal membranes (AROM) is carried out, and Pitocin is given intravenously in the peripheral vein to augment labor. The patient had a spontaneous vaginal delivery of a liveborn infant without complication. Final diagnoses and procedures: (1) Normal spontaneous vaginal delivery, (2) manually assisted delivery, (3) artificial rupture of fetal membranes. Assign the appropriate codes.
Codes: O48.0, Z3A.40, Z37.0, 10E0XZZ, 10907ZC Comments: (1) The administration of Pitocin to augment active labor is not coded separately. (2) In this case, the patient presented in active labor; therefore, do not assign a separate code for the administration of Pitocin. When Pitocin is given to induce labor, it should be coded. Reference: ICD-10-CM and ICD-10-PCSCoding Handbook, 2017 revised Edition, p. 335
Patient at 37 weeks had spontaneous vaginal delivery of a female infant. There was a urethral tear and first degree perineal tear. Perineal tear was repaired with 2-0 vicryl in running lock fashion, with subcuticular closure of the skin. The urethral tear was repaired with 4-0 vicryl in running lock fashion. Mother and infant were stable. Final diagnoses: (1) Normal spontaneous vaginal delivery, (2) repair of urethral and perineal lacerations. Assign the appropriate codes.
Codes: O71.5, O70.0, Z37.0, Z3A.37, 0TQDXZZ, 0HQ9XZZ 10E0XZZ Comments: (1) Code O71.5 is assigned for the urethral laceration. (2) Perineal laceration is assigned to code O70.0. (3) Two procedure codes are used to most appropriately report the different laceration repairs. NSVD would be added as an additional code to show the NSVD per PCS rules for multiple procedures.
Which of the following is an example of a procedure that should be coded multiple times according to the ICD-10-PCS guidelines for multiple procedures? A. Resection of multiple uterine fibroids B. Destruction of two sigmoid colon polyps C. Extraction of multiple toenails D. All of the above
Extraction of multiple toenails
the patient is an 81-year-old female who presented to the emergency department in a coma after having suffered a large intraventricular hemorrhage due to hypertension. How should this be coded?
I61.5 Nontraumatic intracerebral hemorrhage, intraventricular R40.20, Unspecified coma I10, Essential (primary) hypertension Comments: Assign code I61.5 as the principal diagnosis. Codes R40.20 and I10 should be assigned as additional diagnoses. Coma is not inherent to intracerebral hemorrhage. It is appropriate to assign an additional code for the coma. Assigning codes for both the intraventricular hemorrhage and coma will allow information regarding the severity of the patient's condition to be captured. Source: Coding Clinic for ICD-9-CM, First Quarter 2012, p. 14. Reference: ICD-10-CM and ICD-10-PCS Coding Handbook, 2014 Revised Edition, p. 142.
The female patient was admitted with right lower quadrant abdominal pain, diarrhea, fever, chills, and nausea for the past 5 days. Blood and stool cultures were negative. CT of the abdomen ruled out colon disease but was positive for ascites and cirrhosis. This was consistent with the patient's history of cirrhosis due to hemochromatosis. The patient refused paracentesis. Antibiotics were started with improvement of pain and diarrhea. At discharge, the differential diagnosis was acute gastroenteritis or spontaneous bacterial peritonitis. Final diagnosis: (1) Abdominal pain of the right lower quadrant due to gastroenteritis versus spontaneous bacterial peritonitis, (2) cryptogenic cirrhosis due to hemochromatosis Assign the appropriate codes.
K52.9, Noninfective gastroenteritis and colitis, unspecified K65.2, Spontaneous bacterial peritonitis R18.8 Ascites K74.69, Other specified cirrhosis of liver E83.119, Hemochromatosis, unspecified BW20ZZZ, Computerized Tomography (CT Scan) of Abdomen Comments: Either code K52.9 or K65.2 is assigned as the principal diagnosis. This falls under the Official Rules and Guidelines for comparative or contrasting conditions. Either can be sequenced first.
A diabetic nursing home resident was admitted with a one-week history of swelling of the left foot. The physician documents the swelling could be due to cellulitis or primary gouty arthritis and treats the patient for both conditions. Final diagnoses: (1) Swelling of the foot due to cellulitis or gout, (2) diabetes mellitus Assign the appropriate codes
L03.116, Cellulitis of left lower limb M10.072, Idiopathic gout, left ankle and foot E11.9 Diabetes Comments: Either cellulitis or gout could be sequenced first per principal diagnosis rule for contrasting diagnoses.
A 23 years old patient at 22 weeks of pregnancy is admitted with severe shortness of breath. Patient is HIV+ and workup indicates the patient has PCP (Pneumocystis Carinii Pneumonia) which is HIV related. Assign the appropriate codes.
O98.712, B20, B59, Z3A.22 See ICD-10-CM Coding Guideline in Pregnancy, Childbirth and the Puerperium (I.C.15.f) which states "During pregnancy, childbirth, or the puerperium, a patient admitted because of an HIV-related illness should be coded with a principal diagnosis from subcategory O98.7-, Human immunodeficiency [HIV] disease complicating pregnancy, childbirth, and the puerperium, followed by a code for AIDS (B20) and code(s) for the HIV-related illness(es)." A sixth character of 2 indicates that the patient is in the second trimester. An instructional note appears under code B20 indicating that code O98.7- is listed first. An instructional note appears under O98.7 that states to "Use an additional code to identify the type of HIV disease."
An 85-year-old male with aortic stenosis and coronary artery disease status post coronary artery bypass graft, presents to the emergency department (ED) with sharp stabbing pressure-type chest pain in the epigastric area. The patient reported this discomfort was different from that experienced prior to his previous myocardial infarction and was given sublingual nitroglycerin and oxygen, with no improvement. He was later given parenteral Nubain and gastrointestinal cocktail, which provided some pain relief. Cardiac workup was negative for acute myocardial infarction. The physician listed epigastric pain as the final diagnosis. What are the appropriate diagnosis codes?
R10.13, Epigastric pain I35.0, Aortic stenosis I25.10, CAD I25.2 Old MI Z95.1, Presence of aortocoronary bypass graft Comments: Assign code R10.13 as the first-listed diagnosis, since the physician determined that epigastric pain was the reason for the encounter and the Index leads to this code assignment. Even though the patient has a history of gastroesophageal reflux, the physician would need to document that the pain was due to the gastroesophageal reflux in order to assign it as the first-listed diagnosis. Source: Coding Clinic for ICD-9-CM, First Quarter 2002, p. 5.
Which of the following root operations has as its objective "moving a body part to normal or other suitable location"? A. Reposition B. Transfer C. Reattachment D. Transplantation
Reposition
Which root operation would be used to indicate the performance of a total mastectomy? A. Excision B. Resection C. Detachment D. Extraction
Resection
If the coder notes clinical findings outside the normal range but no related diagnosis is stated, what should the coder do? A. Review the conditions possibly responsible for the abnormal findings and select a code for one of those conditions. B. Code the abnormal finding. C. Review the medical record to determine whether additional tests and/or consultations were carried out related to these findings or whether specific related care was given, and ask the physician whether a code should be assigned. D. Review the medical record and code the abnormal finding as a "possible, probable" diagnosis.
Review the medical record to determine whether additional tests and/or consultations were carried out related to these findings or whether specific related care was given, and ask the physician whether a code should be assigned.
The aftercare Z codes should be used to report aftercare for injuries. True or False.
False.
A patient is being seen for aftercare treatment of fracture of left radius. How should this encounter be coded? Z51.89 T14.90XD S52.92XD S52.92XA
S52.92XD
A 53-year-old male patient status post coronary artery bypass graft (CABG) was readmitted to the hospital after he developed redness and purulent drainage deep from the sternal wires. The patient quickly deteriorated after admission, became septic, and went into shock two days after admission. With aggressive intravenous antibiotic management, the patient improved and was later discharged. The physician also documented Methicillin resistant Staphylococcus aureus sepsis and postoperative septic shock from the sternal infection. How should this case be coded?
T81.42XA, Infection following a procedure, deep incisional site, initial encounter. T81.44XA, Sepsis following a procedure, initial encounter. T81.12XA, Post procedural septic shock (post procedure) A41.02, MRSA Sepsis Z95.1, Presence of aortocoronary bypass graft
External cause codes should never be used as a principal or first listed diagnosis. True or false
TRUE
The diabetes mellitus codes are combination codes that include: A.The type of diabetes, the body system affected, and whether the patient is on insulin. B.The type of diabetes, the body system affected, and the complication affecting the body system. C.The type of diabetes, the complication affecting the body system, and whether the patient is on insulin. D.The type of diabetes, the complication affecting the body system, and whether the diabetes is controlled or uncontrolled.
The type of diabetes, the body system affected, and the complication affecting the body system.
When the reason for admission is both sepsis (or severe sepsis) and a localized infection (e.g., pneumonia or cellulitis), which condition should be assigned as the principal or first-listed diagnosis? A.Sepsis or severe sepsis B.Localized infection C.Either sepsis or the localized infection; it doesn't matter. D. It depends on the circumstances of admission.
Sepsis or severe sepsis
13. How should an encounter of an asymptomatic patient tested to confirm a current COVID-19 infection during a COVID-19 pandemic be coded? The test results were negative. A. Z01.84, Encounter for antibody response examination B. Z20.822, Contact with and (suspected) exposure to COVID-19. C. Z11.59, Encounter for screening for other viral diseases D. Z03.818, Encounter for observation for suspected exposure to other biological agents ruled out. References: ICD-10-CM Guidelines COVID-19, Exposure to COVID-19.
Z20.822, Contact with and (suspected) exposure to COVID-19.
Which of the following statements refers to "abnormal findings" for codes describing health examinations with abnormal findings? Condition/diagnosis that is newly found Change in severity of a chronic condition, during a routine physical exam None of the above A and B
A and B
A screening code may be the first listed code if the reason for the visit is specifically the screening exam
A screening code may be the first listed code if the reason for the visit is specifically the screening exam.
How should an encounter of a patient with fever and cough with a positive COVID- 19 test without provider confirmation of the significance of the test result be coded? A. Assign code U07.1, COVID-19 B. Assign only codes for the symptoms (fever, cough) since the provider has not linked the test result to the symptoms. C. Assign code Z20.828, Contact with and (suspected) exposure to other viral communicable diseases since the provider has not linked the symptoms nor the test results to COVID-19. D. None of the above, a physician query is necessary before determining the correct code.
A. Assign code U07.1, COVID-19
A patient has liver metastasis due to adenocarcinoma of the rectum which was resected two years ago. The patient has been receiving radiotherapy to the liver with some relief of pain. The patient is being admitted at this time for management of severe anemia due to the malignancy. The principal diagnosis listed on this admission is: A. Liver metastasis B. Adenocarcinoma of the rectum C. Anemia D. Admission for radiotherapy
A. Liver metastasis
Which of the following statements is NOT one of the conditions that must be met in order for multiple procedures performed during the same operative episode to be coded separately? A. The same root operation is performed on different body parts as defined by distinct values of the body part character. B. The same root operation is repeated in multiple body parts, and those body parts are separate and distinct body parts classified to a single ICD-10-PCS body part value. C. Multiple root operations with the same objectives are performed on the same body part. D. The intended root operation is attempted using one approach but is converted to a different approach.
A. Multiple root operations with the same objectives are performed on the same body part.
The perinatal period is defined as: A.Birth through the first 28 days after birth B.The first month of life C.The first 3 months of life D.Birth through discharge from the hospital
A.Birth through the first 28 days after birth
If a condition complicating the pregnancy develops prior to the current admission/encounter or represents a pre-existing condition, which trimester character should be assigned? A.The trimester character for the trimester at the time of the admission/encounter. B.The trimester character for the trimester when the condition developed. C.The trimester character will depend on the circumstances of admission. D.The trimester character at the time of discharge.
A.The trimester character for the trimester at the time of the admission/encounter.
A patient is diagnosed with MRSA septicemia and pneumonia due to MRSA. How should this be coded?
A41.02, Sepsis due to Methicillin resistant Staphylococcus aureus J15.212, Pneumonia due to Methicillin resistant Staphylococcus aureus
A nursing home resident who sustained a hypoxic brain injury 8 years ago was hospitalized with increasing respiratory failure and fever due to bilateral pneumonia and severe sepsis. The patient has recurrent seizures due to the old intracranial injury, with loss of consciousness from an accidental fall. Final diagnoses: (1) Severe sepsis, (2) bilateral pneumonia, (3) acute respiratory failure, (4) recurrent seizures due to old intracranial injury Assign the appropriate codes.
A41.9, Sepsis, unspecified organism R65.20, Severe sepsis without septic shock J18.9, Pneumonia, unspecified J96.00, Acute respiratory failure, unspecified whether with hypoxia or hypercapnia G40.909, Epilepsy, unspecified, not intractable, without status epilepticus S06.9.x9S, Unspecified intracranial injury with loss of consciousness of unspecified duration, sequela W19.xxxS, Unspecified fall, sequela Comments: (1) The underlying systemic infection is sequenced as principal diagnosis. Since the causal organism is not documented, code A41.9 is assigned, followed by the code for severe sepsis, which is followed by the code for pneumonia, the localized infection. (2) Assign an additional code for respiratory failure, the associated acute organ dysfunction. (3) The code for recurrent seizures, the residual condition of the brain injury, is also reported. (4) The cause of the residual condition, the brain injury, is sequenced after the code for the late effect (residual condition). (5) The external cause of injury code, with the seventh character for sequela, is also assigned. Reference: ICD-10-CM and ICD-10-PCS Coding Handbook, 2014 Revised Edition, pp. 150-152.
Which of the following types of Z codes are used when the initial treatment of a disease has been completed, but the patient requires continued care during the healing or recovery phase? Admission for follow-up examination Admission or encounter for aftercare management Admission for observation and evaluation Screening examinations
Admission or encounter for aftercare management
When a patient has a bilateral condition and each side is treated during separate encounters, how is it coded when one side is treated first and the second side is treated on a separate encounter?
When a patient has a bilateral condition and each side is treated during separate encounters, assign the "bilateral" code (as the condition still exists on both sides), including for the encounter to treat the first side. For the second encounter for treatment after one side has previously been treated and the condition no longer exists on that side, assign the appropriate unilateral code for the side where the condition still exists (e.g., cataract surgery performed on each eye in separate encounters). The bilateral code would not be assigned for the subsequent encounter, as the patient no longer has the condition in the previously treated site. If the treatment on the first side did not completely resolve the condition, then the bilateral code would still be appropriate.
When is it appropriate to assign asymptomatic HIV Z21?
When the patient without any documentation of symptoms is listed as being "HIV positive ", "known HIV", "HIV test positive". DO NOT USE THIS CODE IF THE TERM "AIDS" or "HIV disease" is used or if the patient is treated for any HIV-related illness or is describing as having any condition(s) resulting from his/her HIV positive status, use B20 in this case.
Codes from chapter 18 are assigned as secondary codes under which of the following circumstances? A.When the symptom or sign is not integral to the underlying condition B.When it affects payment C.When desired D.Never
When the symptom or sign is not integral to the underlying condition
A patient had carcinoma of the descending colon, which was resected one year prior to this outpatient encounter. Patient is now seen for colonoscopy to evaluate anastomosis and remaining colon. Colonoscopy showed a normal anastomosis and no evidence of cancer recurrence. Assign the appropriate diagnosis and procedure code(s) and sequence according to coding guidelines.
Z08, Encounter for follow-up examination after completed treatment for malignant neoplasm Z85.038, Personal history of other malignant neoplasm of large intestine Z90.49, Acquired absence of other specified parts of digestive tract Procedure code: 0DJD8ZZ, Inspection of lower intestinal tract, via natural or artificial opening endoscopic Source: Coding Clinic for ICD-9-CM, First Quarter 1995, p. 4.
A patient is seen in the outpatient clinic for colonoscopy due to family history of colon cancer. The patient has no personal history of gastrointestinal disease and is currently without signs and symptoms. Colonoscopy was normal. Assign the appropriate code(s) and sequence according to coding guidelines.
Z12.11, Encounter for screening for malignant neoplasm of colon Z80.0, Family history of malignant neoplasm of digestive organs 0DJD8ZZ Inspection of lower intestinal tract, via natural or artificial opening endoscopic
A woman with no symptoms is referred to the hospital outpatient x-ray department for screening mammogram. The patient is considered high risk for breast cancer secondary to family history of breast malignancy in the mother and sister. How should this encounter be coded?
Z12.31, Encounter for screening mammogram for malignant neoplasm of breast Z80.3, Family history of malignant neoplasm of breast Source: Coding Clinic for ICD-9-CM, Second Quarter 2003, p. 4.
A postmenopausal patient is seen as an outpatient for a bone density study to evaluate for osteoporosis. She has no other signs or symptoms at the present time. What diagnosis code should be used to report this encounter?
Z13.820, Encounter for screening for osteoporosis Z78.0, Asymptomatic menopausal state
A 58-year-old man tested positive for MRSA on routine nasal culture on admission to the hospital. He did not have an infection. How should this be coded?
Z22.322, Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus
If a patient with signs and symptoms is being seen for HIV testing this additional code should be used if counselingis provided?
Z71.7 HIV counseling
HIV infection in pregnancy, childbirth an the puerperium...
a patient admitted(or presenting for an encounter) because of an HIV related illness should have Px code O98.7 HIV complicating pregnancy, followed by B20 then other diagnosis codes
According to CPT® definitions, _____________ is the provision of similar services to the same patient by more than one physician or other qualified health care professional on the same day. a) Concurrent Care b) Recurring Care c) Follow-up Care d) Consultation Care
a) Concurrent Care
A 64-year-old female was discharged with the final diagnosis of acute renal failure and hypertension. What coding guideline applies? a. Use combination code of hypertension and chronic renal failure. b. Use separate codes for hypertension and chronic renal failure. c. Use separate codes for hypertension and acute renal failure. d. Use combination code for hypertension and acute renal failure.
c. Use separate codes for hypertension and acute renal failure. There is not a combination code for acute renal failure and hypertension. Acute kidney failure is not the same as chronic kidney disease (CMS 2021a, Section I.C.9.a.2-3, 47-48; Leon-Chisen 2022, 270-273).
When the provider documentation refers to use, abuse, and dependence of the same substance, what is the coding hierarchy? A.Assign codes for the use and dependence. B. Assign only the code for dependence. C.Assign codes for the use, abuse, and dependence. D. Assign codes for the abuse and dependence.
B. Assign only the code for dependence
How should an unconfirmed diagnosis of COVID-19 infection be coded? A. It should be coded as if established based on the general guideline for " possible," "probable" conditions. B. It should not be coded as confirmed; this condition is an exception to the general guideline for "possible," "probable" conditions. C. It should always be coded as the principal diagnosis. D. It depends on the circumstances of admission.
B. It should not be coded as confirmed; this condition is an exception to the general guideline for "possible," "probable" conditions.
Code O80, Encounter for full-term uncomplicated delivery, is used only when the delivery is entirely normal with a single liveborn outcome. Which of the following situations would not prevent the use of code O80? A.Any postpartum complications. B.An antepartum complication experienced during pregnancy has resolved before the time of admission. C.There is fetal manipulation with forceps. D.There are multiple births.
B.An antepartum complication experienced during pregnancy has resolved before the time of admission.
When an inpatient hospitalization encompasses more than one trimester and remains in the hospital into a subsequent trimester, which trimester character should be assigned for the antepartum complication code? A.The trimester character for the trimester at the time of the admission/encounter. B.The trimester character for the trimester when the condition developed. C.The trimester character will depend on the circumstances of admission. D.The trimester character at the time of discharge.
B.The trimester character for the trimester when the condition developed.
A 13-day-old infant presents for weight recheck and feeding problems. What are the appropriate codes? A.Z00.111 B.Z00.111, P92.9 C.Z00.121, P92.9 D.Z00.70
B.Z00.111, P92.9
A 42-year-old patient with documented history of HIV disease is currently managed on antiretroviral medications. Assign the appropriate codes.
B20, Human immunodeficiency virus (HIV) disease Z79.899, Other long term (current) drug therapy Reference: Chapter 1a2i of the Official Coding Rules & Guidelines and Coding Clinic 1st Quarter, 2022 state diagnosis code B20 is appropriate for patients with documented HIV disease on antivirals. Coding Clinic 4th Quarter, 2020, pages 97-98 clarified HIV disease is specifically classified to code B20. It would not be appropriate to report B20 without provider documentation of either HIV related illness, HIV disease or AIDS.
A 59-year-old female type I diabetic patient presented with a history of fatigue, loss of appetite, and abdominal pain. Hepatomegaly was present on abdominal ultrasound. Liver biopsy was positive for toxoplasma gondii. Clinical signs were also consistent with acute toxoplasmic hepatitis. Final diagnoses: (1) Acute toxoplasmic hepatitis, (2) type I diabetes mellitus maintained on insulin, (3) percutaneous liver biopsy, (4) abdominal ultrasound. Assign the appropriate codes.
B58.1, Toxoplasma hepatitis E10.9, Type 1 diabetes mellitus without complications 0FB03ZX, Excision of liver, percutaneous approach, diagnostic BW40ZZZ, Ultrasonography of abdomen Comments: (1) Code B58.1 identifies the hepatitis as well as the responsible organism. No additional code from chapter 1 is assigned separately for the organism when the organism is identified in the code for the associated condition. Reference: ICD-10-CM and ICD-10-PCS Coding Handbook, 2014 Revised Edition, p. 148.
20. Which of the following statements is true regarding mastectomy followed by breast reconstruction? A. Both resection and replacement of the breast are coded separately. B. Only replacement of the breast is coded C. Only resection of the breast is coded D. Whether to code resection or replacement of the breast is determined by hospital internal policy
Both resection and replacement of the breast are coded separately.
How are changes made to ICD-10-PCS? A. Changes are made by 3M. B. Changes are made by the American College of Surgeons. C. Changes are made through the Coordination and Maintenance Committee process overseen jointly by CMS and NCHS. D. Changes are made by the World Health Organization.
C. Changes are made through the Coordination and Maintenance Committee process overseen jointly by CMS and NCHS.
All of the following procedures would be classified to the root operation Resection, except: A. Left hemicolectomy B. Total mastectomy C. Partial lobectomy of lung D. Total abdominal hysterectomy
C. Partial lobectomy of lung
Which of the following statements is true with regards to coding pregnant diabetic women? A.Pregnant women who are diabetic should be assigned a code from category O24, Diabetes mellitus in pregnancy, childbirth and the puerperium. No code other diabetes code (E08-E13) should be assigned. B. Pregnant women who are diabetic should be assigned the appropriate diabetes code (E08-E13) first, followed by a code from category O24, Diabetes mellitus in pregnancy, childbirth and the puerperium. C. Pregnant women who are diabetic should be assigned a code from category O24, Diabetes mellitus in pregnancy, childbirth and the puerperium, first, followed by the appropriate diabetes mellitus code (E08-E13). D. Pregnant women who are diabetic should be assigned either a code from category O24, Diabetes mellitus in pregnancy, childbirth and the puerperium, or the appropriate diabetes mellitus code (E08-E13). The sequencing does not matter.
C. Pregnant women who are diabetic should be assigned a code from category O24, Diabetes mellitus in pregnancy, childbirth and the puerperium, first, followed by the appropriate diabetes mellitus code (E08-E13).
What does the term "severe sepsis" usually refer to? A.A bad case of sepsis B.Sepsis with associated acute or multiple organ dysfunction C. Systemic inflammatory response syndrome with infection D. Sepsis with fever
C. Systemic inflammatory response syndrome with infection
What are the correct ICD-10-PCS procedure codes for the insertion of a dual chamber pacemaker, open approach, with the pulse generator inserted into a chest pocket and percutaneous insertion of electrodes into the right ventricle and right atrium? A.0JH604Z, 02H63JZ, 02HK3JZ B.0JH606Z C.0JH606Z, 02H63JZ, 02HK3JZ D.0JH639Z, 02H63JZ, 02HK3JZ
C.0JH606Z, 02H63JZ, 02HK3JZ
What is the correct ICD-10-PCS root operation for Cesarean deliveries? A.Delivery B.Removal C.Extraction D.Reposition
C.Extraction
If an expelled fetus has a period of gestation of more than 20 weeks but less than 37 weeks, what is it considered? A.Spontaneous abortion B.Abortion C.Preterm labor with preterm delivery D.Molar pregnancy
C.Preterm labor with preterm delivery
The postpartum period, clinically termed the "puerperium," begins immediately after delivery and includes how many of the subsequent weeks? A.Two B.Four C.Six D.Eight
C.Six
Whats the difference between immunotherapy and chemotherapy
Cancer immunotherapy is a treatment that empowers a patient's own immune system to fight cancer. Chemotherapy, often called "chemo," is a treatment with drugs that kill cancer cells directly
5. If a procedure is attempted by a surgeon but is not successful, what should the coding professional do? A. Not code the procedure. B. Code to the root operation performed and if no root operation performed code to inspection. C. Query the surgeon for instructions D. Code the procedure attempted with a qualifier for "attempted."
Code to the root operation performed and if no root operation performed code to inspection.
An infant is admitted with apnea eight weeks following birth. The pediatrician states that the apnea is a birth-related condition. Assign the appropriate codes.
Code: P28.4
A 20-day-old girl was admitted with severe congestive heart failure. She had experienced worsening dyspnea with a respiratory rate of 60 bpm. Clinical examination revealed a low volume pulse with a delayed peak at a rate of 150 bpm and blood pressure of 80/50 mmHg. The child was treated with dopamine, digoxin, furosemide, spironolactone, and acenocoumarol, and her condition improved. Final diagnosis: Congestive heart failure. Assign the appropriate codes.
Code: P29.0 Comments: Code P29.0 identifies the condition, congestive heart failure, occurring during the perinatal period. Code I50.9 is not appropriate because of the excludes1 note, which excludes neonatal heart failure. Reference: ICD-10-CM and ICD-10-PCS Coding Handbook, 2014 Revised Edition, p. 368.
Previously diagnosed HIV related illness
should always be coded B20 and never R75 or Z21
Patient with HIV disease admitted for unrelated condition, how should the code be sequenced
the code for the unrelated condition as the principal, B20 would be other condition.
When an obstetric patient is admitted and delivers during admission what should be the principal procedure...
the condition that prompted the admission should be sequenced as the principal.
Patient is admitted for a HIV-related condition, how should the code be sequenced?
the principal Dx should be B20
A patient is being treated for congestive heart failure (CHF) and dilated cardiomyopathy related to previous pregnancy following delivery five months ago. The patient complains of swelling of the feet, orthopnea, and palpitations. CT was performed to rule out recurrent pulmonary embolus. Patient was maintained on Coumadin due to previous pulmonary embolism. Patient was admitted to monitor with full-dose heparinization and to treat CHF with intravenous diuretic, ace inhibitors, beta blockers, and Digoxin. A biventricular defibrillator is implanted in the chest (open approach) with insertion of right and left ventricle lead and defibrillator lead into coronary vein (percutaneous approach) vein during the hospitalization. Final diagnoses: (1) Postpartum cardiomyopathy following delivery, (2) congestive heart failure, (3) history of pulmonary embolism, (4) long-term current anticoagulation therapy, (5) CRT-D, (6) CT chest, using low osmolar contrast, (7) EKG. Assign the appropriate codes.
Codes: O90.3, I50.9, Z86.711, Z79.01, 0JH609Z, 02H43KZ, 02HL3KZ, 02HK3KZ, BW241ZZ (CT scan w contrast) Comments: (1) Code O90.3 identifies the cardiomyopathy, so an additional code is not necessary. (2) Codes Z86.711 and Z79.01 are assigned as secondary diagnoses for history of pulmonary embolism and Coumadin maintenance. Since the patient no longer has pulmonary embolism, the condition would not be coded as a current condition. (3) Codes 0JH609Z, 02HK0KZ, 02HL0KZ, and 02H40KZ are assigned for implantation of the biventricular defibrillator total system, including lead placement.
A patient, who delivered at 39 weeks had a routine vaginal delivery of a normal infant. She has asthma for which she takes an inhaler. However, she suffered an obstetrical periurethral laceration during delivery. Final diagnoses and procedures: (1) Spontaneous vaginal delivery complicated by periurethral obstetric laceration, (2) Asthma, (3) assisted vaginal delivery, (4) suture of periurethral laceration. Assign the appropriate codes.
Codes: O99.52, J45.909, O71.82, Z37.0, Z3A.39, 10E0XZZ, 0UQMXZZ Comments: (1) The ICD-10-PCS guideline pertaining to "peri" (B4.1b) only applies when a more specific body-part value is not available. (2) In this case, although the body part was described as "peri-urethral," it is the vulvar tissue, not the urethral tissue, that is torn; a specific body part exists in ICD-10-PCS for "vulva." (3) The patient has asthma for which she takes an inhaler. There were no complications of pregnancy other than the patient having asthma. Therefore, per O99.52 would be principal.
The patient is a 46-year-old with congenital rubella. He also has aortic stenosis and mitral regurgitation with tricuspid insufficiency. Final diagnoses: (1) Congenital rubella, (2) aortic stenosis, (3) mitral regurgitation, (4) tricuspid insufficiency. Assign the appropriate codes.
Codes: P35.0, I08.3 Comments: (1) Codes from chapter 17 can be reported for a patient at any age. Code I08.3 includes all three valves. (2) Code B06.9 is not appropriate for rubella that is documented as a congenital condition. Reference: ICD-10-CM Official Guidelines for Coding and Reporting, p. 62; ICD-10-CM and ICD-10-PCS Coding Handbook, 2014 Revised Edition, p. 356.
A baby with transposition of the great arteries and pulmonary stenosis presents for right modified Blalock-Taussig shunt procedure to augment pulmonary blood flow. At surgery, the aorta and pulmonary artery were separated, and the branch pulmonary arteries were mobilized. The innominate artery was mobilized, an arteriotomy was made, and the proximal anastomosis was created with a Gore-Tex graft. A longitudinal arteriotomy was performed, and the distal anastomosis of the shunt was created to the right pulmonary artery using Prolene suture. Final diagnosis and procedures: (1) Transposition of the great arteries, (2) pulmonary stenosis, (3) modified Blalock-Taussig shunt. Assign the appropriate codes.
Codes: Q20.3, Q25.6, 021Q0JA Comment: Modified Blalock-Taussig shunt involves creation of a "bypass" from the innominate artery to the pulmonary artery with a synthetic type of tissue substitute. In this procedure, the surgeon reroutes the blood flow by placing a graft (usually Gore-Tex) from the innominate or subclavian artery to the pulmonary trunk or to the right or left pulmonary artery. Reference: Coding Clinic, Fourth Quarter 2016.
A three-week-old infant is admitted with projectile vomiting and dehydration. The vomiting is due to the pyloric stenosis. A pyloromyotomy is performed for pyloric stenosis. Final diagnoses: (1) Pyloric stenosis, (2) dehydration, (3) pyloromyotomy. Assign the appropriate codes.
Codes: Q40.0, P74.1, 0D870ZZ (root operation division) Comments: (1) Code Q40.0 is assigned for congenital hypertrophic pyloric stenosis. (2) Code P74.1 is assigned to identify dehydration of newborn. (3) Pyloromyotomy is classified to the root operation "Division" and body part "stomach, pylorus." The objective of the root operation is to expand the opening.
An 87-year-old woman was admitted to the hospital due to a fracture of her left femur after a fall. Her son relates his mother has shown increasingly odd behavior. She seemed to think that he was trying to snatch her purse as he helped her into the car for a ride to church. As she became upset, she tried to get away from him and tripped in her confusion. During the physician's examination, she was disoriented and displayed irrational fears. An open reduction is performed with placement of a metal plate and large screw across the fracture into the femoral head to hold the bones in place. Final diagnoses: (1) Intertrochanteric fracture of the left femur, (2) probable late onset Alzheimer's dementia with behavioral disturbance, (3) hypertension, (4) fall, (5) open reduction with internal fixation. Assign the appropriate codes.
Codes: S72.142A, G30.1, F02.81, I10, W19.xxxA, 0QS704Z Comments: (1) Code F02.81 is assigned to identify the presence of concomitant behavioral disturbances—such as aggressive, combative, or violent behavior—disturbances that are due to the effects of the Alzheimer's disease. The underlying condition that is associated with the dementia is coded before the dementia code. (2) The fracture reduction classified to the root operation "reposition." The trochanter is classified to the body part "upper femur." References: ICD-10-CM Coding Handbook, 2014 Revised Edition, pp. 173, 206, and 487; and Coding Clinic, Fourth Quarter 2000, pp. 40-41
Which of the following root operations is an example of a root operation "to take out some or all of a body part"? A. Extirpation B. Fragmentation C. Division D. Detachment
Detachment
The patient is a ten-year-old girl with severe juvenile scoliosis of the thoracic spine and status post placement of growing rods. The proximal hooks have become dislodged, and she is admitted for removal and replacement of growing rods and proximal hooks. During surgery, the entire growth rod was removed, and a new device was placed. A pedicle hook was placed in the fusion mass on the left, and then a down-going laminar hook was placed around the fusion mass. At the T3 level on the right, a claw construct with an up-going pedicle hook and a down-going laminar hook was placed. The rods were then cut and contoured, and replaced first on the left. The same procedure was repeated on the right. Intraoperative neuromonitoring was also done during surgery. Final diagnosis and procedures: (1) Juvenile scoliosis, (2) dislodged proximal growing rods, (3) removal and replacement of growing rods. Assign the appropriate codes.
Codes: T84.328A, M41.114, 0PS404Z, 0PP404Z, 4A1134G Comments: The complication code would be assigned first as reason for visit with M41.114 identifying the thoracic level Juvenile Scoliosis. (1) At surgery, the old hooks and rods were removed, and new ones were placed. The root operation "Insertion" is not appropriate since the intent of the procedure is to reposition the spine to a suitable location. Therefore, the root operation Reposition is used. (2) "Removal" is the correct root operation for removal of the old rods (3) Intraoperative monitoring of the nervous system during surgery provides recordings and critical detail, which assists the surgeon in preventing neural insults. The monitoring code includes both motor and sensory monitoring. Reference: Coding Clinic, 1st Quarter 2020.
A pregnant patient at 18 weeks' gestation presents for elective termination of pregnancy due to fetal anomalies. Potassium chloride (KCl) was injected into the fetal heart with cessation of fetal cardiac activity. A laminaria was then placed and followed by Pitocin in the peripheral vein, percutaneous approach. The fetus was expelled spontaneously without complication. Final diagnosis: Elective abortion due to fetal anomalies Assign the codes.
Codes: Z33.2, 035.9XX0, 10A07ZX, 10A07ZW, 3E033VJ Comments: (1) Code Z33.2 is assigned as the principal diagnosis since the patient presented for a legally induced abortion due to known or suspected fetal abnormalities. (2) Since an abortifacient and laminaria were both used, codes 10A03ZZ and 10A07ZW are assigned. Code 3E033VJ describes the Pitocin induction.
A newborn had an uncomplicated spontaneous vaginal delivery. The provider noted a flammeus nevus in the sacral area on the newborn physical and progress record for the birth admission. Final diagnosis: Normal newborn, flammeus sacral nevus Assign the appropriate codes.
Codes: Z38.00, Q82.5 Comment: It is appropriate to code the sacral nevus because it is a congenital anomaly present at birth. Congenital anomalies are coded, when identified by the provider, because they can have implications for further evaluation.
Final diagnoses: (1) Newborn affected by mother's use of opiates with withdrawal symptoms. Assign the appropriate codes.
Codes: Z38.01, P96.1, P04.14 Comments: (1) Z38.01 (newborn born in hospital via C-section is the first listed diagnosis as the patient was born during this admission. P96.1 would show the withdrawal symptoms and P04.14 would use the infant affected by maternal use of opiates. P96.1 would be sequenced before P04.14. Reference: Coding Clinic 4th Quarter, 2018, page 24.
The patient with prostate cancer was admitted for chemotherapy; however, during physical examination, the patient was found to be short of breath with a rapid heart rate. There was no known history of cardiac or infectious conditions; basic metabolic panel was normal. Chemotherapy was held for a couple of days while erythropoietin was given for anemia. Final diagnoses: (1) Symptoms related to chemotherapy-induced aplastic anemia, (2) adenocarcinoma of the prostate. Assign the appropriate codes.
Codes: Z51.11, D61.1, T45.1x5A, C61 Comments: (1) When the encounter is for the purpose of chemotherapy, Z51.11 is assigned as principal diagnosis, followed by the code for any complication. (2) Code D61.1 is assigned for drug-induced aplastic anemia, an anemia that is usually associated with a neoplasm or the treatment of neoplasms. It should not be confused with anemia (not specified as aplastic) due to antineoplastic chemotherapy, which is assigned to D64.81. Reference: ICD-10-CM Coding Handbook, 2014 Revised Edition, p. 195 and p. 459.
A patient is seen by her physician for drug level monitoring due to management of Factor V Leiden mutation. Final diagnoses: (1) Factor V Leiden mutation, (2) anticoagulation therapy Assign the appropriate codes.
Codes: Z51.81, D68.51, Z79.01 Comments: (1) Code Z51.81 is used to report encounters for therapeutic drug monitoring. (2) Code Z79.01 is assigned to report the long term use of anticoagulants. Reference: ICD-10-CM Coding Handbook, 2014 Revised Edition, p. 133 and pp. 197-198.
A 13-year-old female with adolescent idiopathic scoliosis of the thoracic spine is admitted for correction of spinal curvature via anterior vertebral tethering. Endoscopic instrumentation was then placed and incisions made over every other rib. Right sided vertebral screws were placed sequentially from T4 - T9 and the tethering cord attached to each screw. Left sided vertebral screws were placed sequentially from T10 - L3. The tethering cord was attached to each screw. The cords were tightened until adequate correction was achieved. Assign the appropriate ICD-10-PCS Codes.
Codes:_M41.124,_0PS443Z Comments: M41.124 appropriate describes adolescent idiopathic scoliosis of the thoracic spine. The objective of the procedure is to "reposition" the spine. Therefore, the root operation would be assigned.
How is a bilateral condition coded if no bilateral code is provided?
If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side.
