Answer key chapter 1

Rationale: The seminal vesicle is found where the vas deferens enters the prostate and is not part of the spermatic cord. The Dartos fascia surrounds the testicles and the spermatic cords within the scrotum. The epididymis is found at the top of the testicle and is not part of the spermatic cord. The vas deferens is found within the spermatic cord.

Rationale: Destruction is the physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent. The laser is an energy source.

Rationale: The prepuce surrounds and protects the head of the penis and is removed during the circumcision procedure.

Rationale: The root operation Resection is used to code this procedure because the term prostatectomy typically describes the removal of the entire prostate. The retropubic approach is an open approach. No device value or qualifier value is appropriate for this code.

Rationale: The root operation Extirpation is used to code the removal of the foreign body from the scrotum. The approach is open and no device or qualifier value is appropriate for this code.

Rationale: This procedure moves the testes into the inner thigh to protect them because the scrotum has been damaged in some way. This procedure would use an open approach, and no device or qualifier value is appropriate for this code.

Root operation: Supplement; Code: 0VUS0JZ

Rationale: The root operation Removal is used to code the removal of the original prosthesis. The insertion of the new prosthesis is coded to the root operation Supplement because it augments the function of the body part. The approach for both procedures is open. The device value for both procedures is J, Synthetic Substitute. No qualifier is appropriate for either code.
Case study coding
1. 0VBQ0ZZ

Rationale: The root operation Excision is used to code the removal of part of the bilateral vas deferens. The body part value Q describes the bilateral vas deferens. The approach is open, and no device value or qualifier value is appropriate for the code. The excision of the small piece of vas deferens is completed between hemostats, and no ligation takes place before the Vas was excised; therefore, the root operation Excision is used, rather than the root operation Occlusion.

Rationale: The root operation Resection is used to code the orchiectomy. The body part value C, Testes bilateral is assigned. The approach is open and no device or qualifier value is appropriate for this code.

Rationale: The root operation Resection is used to code the complete removal of the prepuce. The approach is X, External because the procedure is performed on the skin. No device or qualifier value is appropriate for this code.

Rationale: The root operation Reposition is used to code the advancement of the urethral meatus into the normal position in the glans of the penis. The condition of penile chordee is the abnormal adherence of the head of the penis to the shaft of the penis. The root operation Release is used to code the excision of the adhesions to release the penis. Both procedures are performed using an open approach. No device or qualifier value is appropriate for either code.

Rationale: The vulva is a combination of external female genitalia.

Rationale: The term “subtotal hysterectomy,” also called a supracervical hysterectomy, means that only the uterus is removed and the cervix remains intact.

5. d

Rationale: Body part values for combined structures, such as vagina and cul-de-sac, are available for use in coding the root operations that involve devices or inspection (Change, Insertion, Inspection, Removal, and Revision). The body part values for combined structures are not available for use with any other root operations used in this system.

Rationale: The root operation Excision is coded to describe the vulvar biopsy. The approach is X, External because the excision takes place directly on the skin or mucous membranes. The qualifier X, Diagnostic is assigned for this biopsy.

Rationale: The root operation Drainage is coded. To access the body part in the index, see Drainage, Gland, Vestibular. The approach is open and the documentation states that no drainage device is used. No qualifier is appropriate as the documentation does not state that this was a biopsy.

Rationale: Colpocleisis is a procedure performed to secure the vaginal walls together internally and obliterate the vaginal opening using a vaginal approach. This procedure is performed without endoscopic assistance directly on the vaginal mucosa. Sutures are used; therefore, no device or qualifier are appropriate.

Case study coding
1. 0UDB7ZX

Rationale: The root operation is Extraction with a body part value of B, endometrium and a qualifier of X, Diagnostic.

Rationale: The root operation Excision is used for the procedure on the cervix. Destruction is not appropriate in this case because the loop electrode excised a cone-shaped piece of tissue, as stated in the documentation. If the documentation stated that the electrocautery was used to completely destroy the tissue, the root operation Destruction would be appropriate. The approach is 7, Via Natural or Artificial Opening. No qualifier value is appropriate for this code.

Rationale: The left fallopian tube was suture ligated, meeting the definition of the root operation Occlusion, even though a 1 cm portion of the tube is removed following the ligation. This removal is integral to the ligation process used to create the Occlusion. The right fallopian tube is documented as having a deformity of the fimbria, which was excised, making the intent of this procedure to remove the deformed portion. Therefore, the root operation Excision is most appropriate. The approach for both these procedures is 0, Open, through a small suprapubic incision. In addition, a skin tag was removed from the external genitalia, meeting the definition of the root operation Excision. The approach for the skin tag removal was X, External. No device values or qualifier values are appropriate for any of the codes.

Rationale: The root operation Restriction is used to code the cerclage procedure. The approach is an abdominal approach, or an approach value of 0, Open. An extraluminal device is used to restrict the cervix, for a device value of C, extraluminal device. No qualifier value is appropriate for this code.

Rationale: The exam under anesthesia is the root operation Inspection, which is not coded separately when other root operations are performed. The root operation Destruction is coded for the laser removal of the condylomas of the cervix, vagina, and vulva. The approach value for the cervix and vagina is 7, Via Natural or Artificial Opening and the approach value for the vulva is X, External. No device values or qualifier values are appropriate for any of the procedures.

Rationale: The 7^th character value of 0 describes the classical incision.

3. False

Rationale: These qualifier values describe the body systems of the products of conception, not the pregnant female.

Rationale: Cesarean section delivery of all products of conception are coded with one code.

Rationale: The use of a curette indicates that the root operation Extraction is coded. Retained placental fragments are Products of Conception, Retained. No device or qualifier is appropriate for the code.

Rationale: An external version procedure was performed, which is coded with the root operation Reposition. An external approach is used, as indicated in the procedure name. No device or qualifier is appropriate for this code.

Root: Division; Code: 0W8NXZZ

Rationale: Spontaneous vaginal deliveries are coded with only one code in ICD-10-PCS. The root operation Delivery is used to code this case. The episiotomy is coded to the root operation Division. The body part value is N, Perineum, female in the anatomical regions, general body system, and the approach is external. The episiotomy repair is not coded because closure of an operative incision is included in the procedure.
7. Root: Extraction; Code: 10D07Z3

Root: Division; Code: 0W8NXZZ

Rationale: The use of forceps determines that this is the root operation Extraction. The qualifier value of 3, low forceps is assigned. The episiotomy is coded to the root operation Division. The body part value is N, perineum, female in the anatomical regions, general body system, and the approach is external. The episiotomy repair is not coded because closure of an operative incision is included in the procedure.
9. Root operation: Extraction; Code: 10D07Z7

Rationale: The root operation Extraction is used to code this procedure because a form on instrumentation was used to extract the products of conception. The approach value of 7 is assigned because it was a vaginal delivery, through a natural opening. The qualifier value of 7 is assigned for internal version.

Rationale: The root operation Extraction is used to code cesarean section deliveries. The approach is open and the qualifier identifies the uterine approach as low cervical in this case.

Rationale: Delivery was accomplished without the assistance of instruments, therefore the root operation Delivery is coded. The root operation Delivery always uses an external approach. No device value or qualifier value applies to this code.

Rationale: The root operation Extraction is coded for the Cesarean Section. The approach is open, and the qualifier is 0 for a classical incision.

Rationale: The root operation is Irrigation in the Administration Section of ICD-10-PCS. The main term in the index is Irrigation with a sub-term of Peritoneal cavity and the substance is Dialysate.

Rationale: The interrogation of the pacemaker is the root operation Measurement. The function/device value is S, Pacemaker. There is no qualifier.

Rationale: Urinary manometry is measuring the pressure within an organ, in this case the urinary bladder. The root operation is Measurement, and the code is 4A0D7BZ. The entire 7 characters of the code are provided in the index.

Rationale: The root operation Introduction is used to code the administration of the serum, toxoid, or vaccine. The injection location is intramuscular, and the approach is percutaneous. The substance value is 4, Serum, Toxoid, or Vaccine, and there is no qualifier.

Rationale: The root operation Introduction is used to code the administration of the anti-inflammatory into a joint of the spine. The introduction of the anesthetic is not coded separately. It is injected to ease the pain of the anti-inflammatory injection.

Root: Monitoring; Code: 4A100BZ

Root: Excision; Code: 0JBM0ZZ

Root: Repair; Code: 0NR007Z

Rationale: The root operation Drainage is used to code the procedure to drain the intracranial abscess, body part value 7, Cerebral Hemisphere. The approach is open through the craniectomy. The device value is 0, Drainage Device, and there is no qualifier value for this code. The root operation Monitoring is used to code the placement of the intracranial pressure device and the monitoring. The approach is open. The function/device value is B, Pressure, and there is no qualifier for this code. The root operation Excision is used to code the harvesting of the fascia graft from the patient’s upper leg using an open approach. The root operation Replacement is used to temporarily replace the skull. The device value is 7, Autologous Tissue Substitute. No qualifier value is appropriate for this code.
Case study coding
1. 4A00X4Z

Rationale: The root operation Measurement is used to code this procedure for measuring the electrical activity of the central nervous system. The approach is X, External. The function/device value is 4, Electrical Activity, and there is no qualifier for this code.

Rationale: The root operation Introduction is used to code this injection. This is an epidural injection of steroid, mixed with local anesthetic for pain control. This is coded to the substance value 3, Anti-inflammatory. The approach is percutaneous. The Xylocaine anesthetic is only added to lessen the pain of the injection, and is not coded separately. The Marcaine and Fentanyl are regional anesthetics that ease the pain along the region of the epidural space being injected and is coded separately. Only local anesthetic is included in the injection of the substance.

Rationale: The root operation Measurement is used to code this EKG. The body system being measured is 2, Cardiac. The approach is X, External. The function/device value is 4, Electrical Activity, and there is no qualifier value.

Rationale: Achalasia is a disorder in which peristalsis in the esophagus is reduced. This can be treated by Botox injection, coded with the root operation Introduction. This section of ICD-10-PCS does not provide specific body part values and, therefore, G, Upper GI is coded for this injection into the esophagus. The approach value is 8, Via Natural or Artificial Opening, Endoscopic. The substance value is G, Other Therapeutic Substance, and the qualifier is C, Other Substance. See Coding Tip in this chapter on Botox.

Rationale: The root operation Monitoring is used to code this Holter monitor that’s worn over a 24 hour period. The body system being monitored is 2, Cardiac. The approach is X, External. The function/device value is 4, Electrical Activity and the qualifier value is 5, Ambulatory to indicate that the patient wore the device during daily activity.

Check Your Understanding

1. Cardiac assistance using an implanted impeller pump

Rationale: This procedure is the root operation Assistance of the cardiac system. The qualifier value of D is an impeller pump.
3. c

Rationale: ECMO is coded to the root operation Performance because it takes over the entire function of circulatory function and provides oxygenation at the membrane level.

Rationale: Mechanical ventilation uses equipment. Mouth-to-mouth resuscitation is a nonmechanical method for performing ventilation.

Procedure statement coding
1. Root: Assistance; Code: 5A09357

Rationale: The root operation Assistance is used to code this procedure because the patient can breathe independently but needs assistance with breathing in enough oxygen. The body system value is 9, Respiratory. The duration value is 3, Less than 24 Consecutive Hours and the function is 5, Ventilation. The qualifier value is 7, Continuous Positive Airway Pressure.

Rationale: The root operation Performance is used to code the mechanical ventilation for greater than 96 hours. The function value is 5, Ventilation. There is no qualifier for this code.

Root: Performance; Code: 5A1221Z

Rationale: The root operation Resection is used to code the complete removal of the pericardium, body part value N in the Heart and Great Vessels body system. This procedure used an open approach because CP Bypass was used. The CP Bypass is coded with the root operation Performance.
7. Root: Shockwave Therapy; Code: 6A930ZZ

Rationale: The root operation Shockwave Therapy is used to code this single session of therapy to the musculoskeletal system. Shockwave therapy is used to treat calcifications of the tendons.

Rationale: The root operation Pheresis is used to code the procedure of separating the plasma from the other blood components outside of the body to treat a disease. The duration value is 0, Single Treatment, and the 7^th character qualifier is 3, Plasma.

Rationale: The root operation Restoration is used to code cardioversion. This is the only procedure coded with the root operation Restoration in ICD-10-PCS.

Rationale: The root operation Bypass is used to code the bypass from 2 coronary artery sites from the aorta using the autologous venous free graft from the right greater saphenous vein. The root operation Bypass is used to code the bypass from the left internal mammary artery which was anastomosed to one coronary artery site. There is no device value for this code because the LIMA is not a free graft. The LIMA is the source of the bypass. In addition, the root operation Excision is used to the code harvesting of the greater saphenous vein for the graft, using a percutaneous endoscopic approach. The bypass procedure used an open approach because CP Bypass was used. The CP Bypass is coded with root operation Performance. The cardioplegia, or the introduction of cold solution into the heart to protect it during the period of ischemia on CP Bypass, is not coded separately because this is integral to the CP Bypass procedure.

Rationale: The root operation Assistance is used to code the use of the IABP because it assists the cardiac output that is insufficient without the pump. The duration value is 2, Continuous, because the patient will continue on the balloon pump either permanently or until the heart has sufficiently healed to allow the removal. The insertion of the balloon pump is not coded as it is not considered a device in ICD-10-PCS.

Rationale: The qualifier value 6 in Section 8, Other Procedures means Isolation.

Root: Chiropractic Manipulation; Code: 9WB2XHZ

Rationale: The root operation is Manipulation. The body region values are 1, Cervical and 2, Thoracic. The approach is always X, External. The method is H, Short lever specific contact, and there is no qualifier.
3. Root: Excision; Code: 00B70ZZ

Method: Computer Assisted; Code: 8E09XBZ

Rationale: The root operation Excision is used to code the excision of the lesion within the cerebral hemisphere. The approach is open (craniotomy), and there is no device value or qualifier appropriate for this code. An additional code is required for the computer-assisted procedure method. The main term in the index is Computer Assisted. The body region is 9, Head and Neck Region. The approach is X, External. There is no qualifier for this code.
5. Root: Osteopathic Treatment; Code: 7W05X4Z

Rationale: The root operation is Treatment, found in the index under Osteopathic Treatment. The body region value is 5, Pelvis. The approach is X, External. The method value is 4, Indirect and there is no qualifier.

Rationale: The main index term is Near Infrared Spectroscopy, and the body region is 2, Circulatory System even though the location is the head. The vessels are being evaluated, not the head. The approach is percutaneous, and there is no qualifier.

Rationale: The main index term is Chiropractic Manipulation. The body region value is 2, Thoracic, and the method value is K, Mechanically assisted. The approach is always X, External. There is no qualifier for this code.

Root: Computer assisted procedure; Code: 8E09XBG

Rationale: The root operation Excision is used to describe the partial removal of the pineal gland, also called the pineal body. The approach is open, and there no device value or qualifier value appropriate for this code. An additional code is required for the computer assisted portion of the procedure. The main term in the index is Computer assisted procedure. The body region value is 9, Head and Neck Region. The approach is X, External. The method value is B, Computer assisted procedure, and the qualifier value is G, with computerized tomography.

Case study coding

Rationale: The root operation Replacement is used to code these procedures. The right knee was replaced with a synthetic substitute, device value J. The approach is open and the qualifier value is 9, Cemented. The removal of the native joint is not coded separately. The computer assisted navigation should be coded separately. The main index term is Computer assisted procedures, and the body region value is Y, Lower Extremity. The approach is X, External. The method value is B, Computer assisted procedure, and the qualifier value is Z, no qualifier.

Rationale: Acupuncture only has two codes in ICD-10-PCS. When the procedure is therapeutic and not for anesthesia, the only code provided in the index is 8E0H30Z.

Omnipaque 140, 180, 240, 300, and 350

Optiray 160, 240, 300, 320, and 350

Oxilan 300 and 350

Ultravist 150, 240, 300, and 370

Visipaque 320