Answer key chapter 1

Rationale: The index directs the coder to use device value 8, Defibrillator Generator for the Implantable Pacing Cardioverter-Defibrillator when inserting it into the Subcutaneous pocket in the chest. The approach is open. The root operation Insertion is used to code the two leads (dual chamber device). The body part values are 6, Atrium, Right and K, Ventricle, Right. The approach is 3, Percutaneous, because they are placed there without visualization of the operative site. The device value is K, Cardiac Lead, Defibrillator. The root operation Fluoroscopy is used to code the fluoroscopic guidance. The body part value is 4, Heart, Right. The contrast value is 1, Low Osmolar. Note: Consult facility policy to determine if a code for intra-operative imaging should be assigned.

Rationale: Two codes are required, one for the infusion device into the superior vena cava and one for the reservoir in the subcutaneous tissue of the chest. The root operation Insertion is used to code both procedures. The device value for the infusion device is 3, Infusion Device. The device value for the implantable portion in the subcutaneous tissue is W, Vascular Access Device, Reservoir. Both the catheter and the reservoir are placed using an open approach because the catheter was placed via a cutdown.

Rationale: The root operation Excision is used to code the harvesting of the greater saphenous vein from the left leg via incision. The root operation Bypass is used to code the grafting of the greater saphenous vein to three coronary artery sites (body part value 2) and to the aorta (qualifier value W). The root operation Bypass is used to code the bypass to one coronary site (body part value 0) from the left internal mammary artery (qualifier value 9). There is no device value because the left internal mammary artery remains connected to create the bypass. Cardiopulmonary bypass is coded using the root operation Performance.

Rationale: The root operation Repair is used to code the closure of the atrial septal defect using a suture. The root operation Repair is used to code the repair of the chordae tendineae. The root operation Supplement is used to code the reinforcement of the mitral valve with an annuloplasty ring. The device value is J, Synthetic Substitute. Cardiopulmonary bypass is coded using the root operation Performance.

Rationale: The root operation Control is used to fulgurate the bleeders from the previous procedure. The body system is Anatomical Regions, General, and the body part value is R, Genitourinary system because the root operation Control is assigned to large body areas rather than individual body parts. The approach for both procedures is 8, Via Natural or Artificial Opening, Endoscopic. There are no device values or qualifier values for either code. The removal of the clots is included in the Control procedure and is not coded separately.

Rationale: The root operation Extirpation is used to code the removal of the calculus through an open incision. The body part value is 4, Kidney Pelvic, Left. No device or qualifier values are appropriate. There were 3 calculi removed and, therefore, this code is assigned three times. The root operation Dilation is used to code the placement of the stent into the left ureter. The body part value is 7, Ureter, Left. The approach is open, and the device value is D, Intraluminal Device. There is no qualifier.

Rationale: The root operation Reposition is used to code the relocation of the urethral meatus to the central position in the glans penis. The body part value is D, Urethra. The approach is open. The root operation Release is used to code the degloving of the penis to release it from the penopubic fat. The body part value being released is S, Penis. The root operation Resection is used to code the complete removal of the prepuce, body part value T. The approach for the circumcision is X, External.

Rationale: Four individual body part values are removed during this procedure (uterus 9, cervix C, bilateral fallopian tubes 7, and bilateral ovaries 2). The root operation Resection is used to code the complete removal of all these organs. The approach is open, and there are no device or qualifier values.

Rationale: A medical indication is given for the procedure (interfering with vision), indicating that this is not the root operation Alteration. The root operation Excision is used to code the removal of a piece of levator muscle from each eyelid. The index directs the coder to code the eyelid body part for the levator palpebrae superioris muscle. The body part values are P, Upper Eyelid, Left and N, Upper Eyelid, Right. The approach is open and no device or qualifier values are appropriate.

Rationale: The root operation Excision is used to code the removal of the subcutaneous lesion of the lower leg. The approach is open, and the qualifier is X, Diagnostic because this was sent for identification. The root operation Excision is used to code the chondroplasty, or articular shaving, of the knee joint (knee cartilage is a knee structure). The approach is 4, Percutaneous Endoscopic. The root operation Removal is used to code the removal of the old tibial fixation device. The body part is H, Tibia, Left. The device value is 4, Internal Fixation Device. The root operation Supplement is used to code the non-autologous graft to the anterior cruciate ligament of the knee. The body part value is P, Knee Bursae and Ligament, Left, and the device value is K, Nonautologous Tissue Substitute.

Rationale: The root operation Excision is used to code the removal of the vocal cord lesions. Two codes are required because lesions were excised from both the left and right vocal cord and no bilateral body part value is available. The body part values are V, Vocal Cord, Left and T, Vocal Cord, Right. The approach value is 8, Via Natural Opening, Endoscopic. The root operation Excision is used to code the removal of the skin lesion of the face, body part value 1. The approach is X, External.

Rationale: The root operation Excision is used to code the transbronchial biopsy (of the lung). The approach is 8, Via Natural or Artificial Opening, Endoscopic. The qualifier is X, Diagnostic because it is a biopsy. The body part value is C, Upper Lung Lobe, Right. The qualifier is X, Diagnostic because it is a biopsy. The root operation Excision is used to code the endobronchial biopsy of body part value 4, Upper Lobe Bronchus, Right. The approach is 8, Via Natural or Artificial Opening, Endoscopic. The qualifier is X, Diagnostic because it is a biopsy. The root operation Extirpation is used to code the removal of the mucus plug from body part value 4, Upper Lobe Bronchus, Right.

Rationale: The root operation Insertion is used to code the insertion of the Swan Ganz catheter into the pulmonary trunk, body part value P. The device value is 2, Monitoring Device because of the Swan Ganz monitoring the output into the pulmonary artery. The root operation Removal is used to code the removal of the External Heart Assist Device (device value R) from the heart, body part value A. A TEE (transesophageal echocardiogram is completed intraoperatively and is coded with the root type Ultrasonography. The body part value is 6, Heart, Right and Left, and the qualifier value is 4, transesophageal. Cardiopulmonary bypass is coded using the root operation Performance.

Rationale: The root operation Destruction is used to code the laser debridement of the left false (vocal) cord, which is the larynx (S) based on the body part key, the subglottis (coded to the glottis based on Guideline 4.1a), also the larynx (S) based on the body part key and the trachea (1). The root operation Introduction is used to code the injection of Avastin, which is an antineoplastic agent (substance value 0) and a monoclonal antibody (qualifier value M), also called Bevacizumab, into the respiratory tract (F). The approach for all these procedures is 8, Via Natural or Artificial Opening, Endoscopic.

Rationale: SPECT is coded with the root type tomographic nuclear medicine imaging. The body part value is 2, Lungs and Bronchi, and the radionuclide value is 1, Technetium 99m.