Answer key chapter 1

Rationale: The ICD-10-PCS index directs the coder to use the root type Plain Radiography to code this procedure.

Rationale: Positron Emission Tomography is a root type in the Nuclear Medicine section of ICD-10-PCS.

Rationale: The Imaging section is organized in a manner similar to the Medical and Surgical section of ICD-10-PCS with the tables for one body system together and the tables for the root types in the same order under each body system.

Rationale: The root type for this procedure is Ultrasound. The index entry under Internal Carotid, Bilateral provides a 7 character code of B348ZZ3 that must be checked in the tables. From the table, the coder should determine that this was not an intravascular study and code B348ZZZ should be assigned to show that no qualifier was appropriate.

Rationale: The root operation Introduction is used to code this epidural steroid injection. The body part value S is assigned for the Epidural Space and the substance value is 3, Anti-inflammatory. The procedure is performed with the use of fluoroscopic guidance. This is coded with the root type of Fluoroscopy and the body part value 9, Lumbar Spine. Isovue is low osmolar contrast material. The last 2 characters are Z, None because the qualifier of Guidance is not available for this body system and root type.

Rationale: The root operation Drainage is used to code this lumbar puncture procedure. The body part value U, Spinal Canal is assigned with an approach of 3, Percutaneous. The qualifier value of X, Diagnostic is assigned because the CSF was drained for diagnostic purposes. The procedure was performed under fluoroscopic guidance. This is coded with the root type of Fluoroscopy and the body part value 9, Lumbar Spine. The last 3 characters are Z, None because the qualifier of Guidance is not available for this body system and root type.

Root: Plain Radiography, left femur densitometry Code: BQ04ZZ1

Rationale: The index entry for densitometry directs the coder to the root type Plain Radiography of the axial skeleton. In this case, the lumbar spine and the left femur are tested for bone density. The qualifier of 1, Densitometry is assigned.
9. 02713DZ, B2111ZZ, 4A023N7, 5A02210

Rationale: The root operation Dilation is assigned for the PTCA procedure of two coronary artery sites. The approach is 3, Percutaneous and the device value is D, Intraluminal device for the bare metal stents. The multiple view coronary angiograms are coded with the root type Fluoroscopy and low osmolar contrast was used. The left ventricular pressure measurement is coded with the root operation Measurement and is measured percutaneously. The function value is N, Sampling and Pressure and the qualifier value is 7 for the location of left heart. The root operation Assistance is used to code the use of the balloon pump that assists the cardiac output. The duration value is 2, Continuous, because the patient will continue on the balloon pump until the heart has sufficiently healed to allow the removal.

Rationale: The root operation Measurement is used to code the exercise portion of the stress test. The approach is X, External. The Function/Device value is M, Total Activity and the qualifier is 4, Stress. The baseline EKG is not coded separately as this is integral to the complete stress test. The SPECT images are coded with the root type Tomographic Nuclear Medicine Imaging of the myocardium because the images were taken of the cardiac wall. The radionuclide value is 1, Technetium 99m and the 6^th and 7^th character qualifiers are Z.

Rationale: The angioplasty is coded with the root operation Dilation of the lower arteries and the body part 9, Renal Artery, Right. The approach is 3, Percutaneous, and there is no device or qualifier value. The angiograms are coded with the root operation Fluoroscopy of the lower arteries and the body part value 8, Renal Arteries, Bilateral. The last 3 characters of the code are Z, None.

Rationale: The root operation Dilation is used to code the PTCA of the left circumflex coronary artery. One site is treated and coded with body part value 0, Coronary Artery, One Site. The approach is 3, Percutaneous and the device value is 4, Drug-eluting Intraluminal Device. There is no qualifier value. The root type Fluoroscopy is used to code the coronary angiograms of a single artery, body part value 0. The contrast value is 1, Low Osmolar and there are no 6^th or 7^th character qualifiers.

Rationale: The definition of the cochlear implant treatment root type is “application of techniques to improve the communication abilities of individuals with cochlear implant.”

Procedure statement coding

1. Root: Electroconvulsive Therapy; Code: GZB2ZZZ

Rationale: The root type is electroconvulsive therapy. The index has a cross reference from electroshock therapy to electroconvulsive therapy. This is a bilateral-single seizure treatment, and the index provides the entire 7 character code.
3. Root: Intellectual and Psychoeducational test; Code: GZ12ZZZ

Rationale: WAIS testing is the Wechsler Adult Intelligence Scale test (from the examples of psychological tests in this chapter), an intellectual and psychoeducational test in the Mental Health Section. This service is root type 1, and this test is type qualifier 2. All mental health codes end in ZZZ.

5. Root: Motor Treatment; Code: F07Z8FZ

Rationale: The root type is 7, Motor Treatment and the type qualifier is 8, Transfer training. The equipment value is F, Assistive, Adaptive, Supportive, or Protective. The qualifier is Z, None.

Rationale: The root type Detoxification Services is used to code this procedure. The index provides all 7 characters for this code.

Case study coding

Rationale: The root type Individual Psychotherapy is assigned for this service. This is located in the index under the main term Psychotherapy with a sub-term of Individual and then under Mental Health Services. This is supportive psychotherapy because the plan section indicates that the Insurance has approved up to 8 more visits of supportive therapy.

Rationale: The brainstem auditory evoked response (BAER) is a measurement of the central nervous system response to an auditory stimulus. The root operation Measurement is used to code this procedure. The approach is X, External. The Function/Device value is V, Stimulator and no qualifier value is appropriate for this code. The Evoked Otoacoustic Emissions (EOAE) is a diagnostic hearing test to determine if the hair cells in the cochlea are functioning. The root operation Hearing Assessment is used to code this procedure. The type qualifier value is N, Evoked Otoacoustic Emissions, Diagnostic. The equipment value is 6, Otoacoustic Emission (OAE) and there is no qualifier value appropriate for this code.

Rationale: The root operation Hearing Assessment is used to code speech recognition threshold testing of auditory processing. The type qualifier is auditory processing. The equipment value is P, computer because the words are spoken by the computer at a set decibel level. There is no qualifier value appropriate for this code. The root operation Device Fitting is used to code the hearing aid fitting service. The type qualifier is 2, Binaural hearing aid. The equipment value is 5, Hearing Aid Selection/Fitting/Test, and there is no qualifier value appropriate for this code.

Rationale: The root operation Hearing Assessment is used to code this procedure. The body system value is Z, None. The type qualifier is hearing screening. The Equipment value is 1, Audiometer. There is no qualifier value appropriate for this code.

Exercises and Case Studies
2013 Updates
Update exercise #3 to read “Radiofrequency facet denervation of the right L2-L3, L3-L4 by rhizotomy, open approach.”
Update Case Study #35 to read “the greater saphenous vein…” at the top of page 570.
Answer Key
Exercises
1. Root: Stereotactic Radiosurgery; Code: DG20JZZ

Rationale: The root type Stereotactic Radiosurgery is used to code the destruction of the pituitary tumor using gamma beams. The body part value is 0, Pituitary Gland, and the modality qualifier is J, Stereotactic gamma beam radiosurgery.

Root: Division; Code: 018B0ZZ

Rationale: Radiofrequency rhizotomy or neurotomy is a therapeutic procedure designed to divide the nerves that innervate the facet joints with highly localized heat generated with radiofrequency. The root operation Division is used to code this procedure. The approach is open. In this case, two nerves are divided and therefore, two of the same code are assigned, based on Guideline B3.2b.
5. Root: Insertion; Code: 0SH03BZ

Rationale: The root operation Insertion is used to insert the Spinal Stabilization Device, Interspinous Process, device value B into a lumbar joint. The approach is 3, Percutaneous.

Rationale: Manometry is the measurement of pressure within an organ. For this test, a thin catheter is passed through the nose, into the esophagus and into the stomach. The pressure is measured as the patient swallows. The root operation is Measurement and the body part value is B, Gastrointestinal. The approach is 7, Via Natural or Artificial Opening, and the function/device is B, Pressure. There is no qualifier.

Root: Insertion; Code: 0QHJ08Z

Rationale: The root operation Insertion is used to place the external fixation device for limb lengthening. The Z osteotomy is part of the approach and is integral to the limb lengthening process. Two codes are required, one for each bone of the lower leg. The device value, 8, External fixation device, limb lengthening is assigned to both.
11. Root: Excision C6; Code: 0PB30ZZ

Root: Excision C7; Code: 0PB30ZZ

Root: Fusion C5–C6, C6–C7; Code: 0RG20K0

Root: Fusion C7–T1; Code: 0RG40K0

Root: Insertion, internal fixation device, cervicothoracic vertebral joint; Code: 0RH404Z

Rationale: The corpectomy is the root operation Excision of the anterior portion of the vertebra (see figure 16.3 for a picture of the complete vertebra). This procedure is performed on two vertebrae and therefore, two codes are assigned. The approach is open. The arthrodesis is coded with the root operation Fusion of three vertebral joints, two cervical joints (C5–C6 and C6–C7) and one cervicothoracic joint (C7–T1). The anterior instrumentation is a plate placed across the entire fusion from C5–T1. This is the root operation Insertion, and the device is an internal fixation device, cervicothoracic vertebral joint. This is not a spinal stabilization device because spinal stabilization devices are all inserted on the posterior portion of the vertebra (interspinous process, pedicle, or facet joint).

Root: Reposition, thoracic aorta, open; Code: 02SW0ZZ

Rationale: The Jatene procedure is an arterial switch or the total correction of transposition of great vessels. “In a normal heart, the aorta comes from the left side of the heart, and the pulmonary artery comes from the right side. Transposition of the great vessels is when these arteries come from the opposite sides of the heart. Correcting transposition of the great vessels requires open-heart surgery. The most common repair is an arterial switch. The aorta and pulmonary artery are divided. The pulmonary artery is connected to the right ventricle, where it belongs. Then, the aorta and coronary arteries are connected to the left ventricle, where they belong” (University of Maryland Medical Center, 2011). The root operation for this procedure is Reposition. Two codes are required, one for the pulmonary trunk and one for the thoracic aorta. Both procedures are performed using an open approach.
15. Root: Fusion; Code: 0SG107J

Root: Insertion; Code: 0SH00CZ

Root: Excision; Code: 0PB10ZZ

Rationale: The root operation Fusion is used to code the arthrodesis of two levels (L1–L2 and L2–L3). The device value is 7, Autologous Tissue Substitute. This is a posterior approach to the anterior spine, or qualifier value J. The posterior lumbar segmental instrumentation is coded with the root operation Insertion, and the device value is C, Spinal Stabilization device, pedicle-based, because the instrumentation is screwed into each pedicle of the spine. The autologous bone graft is coded with the root operation Excision and a body part value of 1, Rib Right.

Rationale: The root operation Supplement is used to code this procedure because the inflatable prosthesis augments the work of the corpora cavernosa and spongiosum in the erection process. The device value is J, Synthetic Substitute.

Rationale: The root operation Destruction is used to code the injection to destroy the trigeminal nerve. The trigeminal nerve is part of the central nervous system in ICD-10-PCS and is body part value K. The approach is 3, Percutaneous because this was an injection. The use of the Phenol is identified in the root operation Destruction and is not captured in any other way in the code.

Rationale: This procedure involves the insertion of a bar under the sternum to expand the chest wall. The bar supplements the chest wall and therefore, the root operation Supplement is coded. The bar is placed percutaneously with the aid of a scope and fixed at either end to the rib cage. The device value J, Synthetic Substitute, is assigned. No qualifier is appropriate for the code.

23. Root type: Psychological Tests; Code: GZ10ZZZ

Rationale: The root type is psychological tests, value 1, within the Mental Health section of ICD-10-PCS. The Mullen Scales of Early Learning are a developmental test, type qualifier 0. The remaining values for the code are Z, None.

Root: Introduction; Code: 3E013GC

Rationale: The root operation Insertion is used to place the tissue expander into the subcutaneous tissue of the scalp. The device value is N, tissue expander. The root operation Introduction is used to code the filling of the tissue expander. The approach is 3, Percutaneous, and the substance value is G, Other Therapeutic Substance. The qualifier is C, Other Substance.
27. Root: Beam Radiation; Code: D7031ZZ

Rationale: The root operation Beam Radiation is used to code this procedure. The treatment site is 3, Lymphatics, Neck, and the modality qualifier is 1, Photons 1–10 MeV.

Rationale: HBO is hyperbaric oxygenation. In this base, the HBO is used to treat the carbon monoxide poisoning in the whole body. Therefore, the root operation Decompression is coded. This is a single treatment for the 5^th character of 0.

Rationale: One code is assigned for the neurostimulator lead and another for the stimulator generator. The root operation Insertion is coded for both procedures and they both use the open approach. The device value for both is M. Neither code has a qualifier value. The fluoroscopy guidance is coded using the root type Fluoroscopy of the body part value 7, Thoracic spine.

Rationale: The root operation Bypass is used to code this procedure. The body part value is K, Femoral Artery, Right. The approach is open. The device value is 9, Autologous Venous Tissue because the greater saphenous vein was harvested. The qualifier value is N, Posterior Tibial Artery because that is the artery to which the bypass was created. The root operation Excision is used to code the harvesting of the right greater saphenous vein graft. The body part value is P, Greater Saphenous Vein, Right. The approach was open, and there were no device or qualifier values.

Rationale: Angiography is coded with the root type Fluoroscopy. There is a body part value that defines the common combination of Aorta and Bilateral Lower Extremity Arteries, which is documented here. The contrast value is 1, Low Osmolar because Omnipaque is low osmolar contrast. There is no 6^th or 7^th character qualifier.

Rationale: A Mitrofanoff is a bypass between the bladder and the skin, using tissue from the appendix to form the new opening, referred to as a Mitrofanoff channel. The patient must have an indwelling catheter in this channel or catheterize themselves routinely every few hours. The root operation Destruction was used to code the cautery destruction of excessive tissue in the bladder. The body part value is B, Bladder, and the approach is 8, Via Natural or Artificial Opening, Endoscopic. There are no device or qualifier values.

Rationale: The root operation Supplement is used to code this procedure because the inguinal hernia repair is completed with the use of Marlex mesh to supplement the inguinal region. The body part value 5, Inguinal Region, Right is assigned. The approach is Open, and the device value is J, Synthetic Substitute. There is no qualifier.

Rationale: Guideline B3.2b directs the coder to code multiple procedures when the same root operation is repeated at different body sites that are included in the same body part value. Therefore, six of the same procedure codes are assigned. The body part value is 0, Prostate. The approach is 7, Via Natural or Artificial Opening and the qualifier of X, Diagnostic is assigned because these are biopsies. The digital rectal exam of the prostate (root operation Inspection) is not assigned because a more definitive procedure is performed at the same site. Note: Consult facility policy to determine if a code for intra-operative imaging is to be assigned.

Rationale: The root operation Dilation is used to code the balloon dilation of the lower esophagus, body part value 3, Esophagus, Lower. The approach is 8, Via Natural or Artificial Opening, Endoscopic. There is no device or qualifier value. The upper endoscopy is not coded separately because this was the approach. In addition, the upper endoscopy would be the root operation Inspection, which is not coded if a more definitive procedure is performed at the same time.

Rationale: The root operation Measurement is used to code the pressure sampling in the left and right heart, body part value 2, Cardiac. The function/device value is N, Sampling and Pressure. The qualifier is 8, Bilateral. The angiography is coded using the root type Fluoroscopy. All were completed using Omnipaque, a low osmolar contrast. The aortogram is body part 0, Thoracic Aorta. The bilateral ventriculograms is body part value 6, Heart, Right and Left. The inferior venacavogram is body part 9, Inferior Vena Cava. The right and left pulmonary arteries are body part values S and T.

Rationale: The root operation Introduction is used to code this injection of anti-inflammatory into the epidural space, body part value S, Epidural Space. The approach is 3, Percutaneous. The substance value is 3, Anti-inflammatory. There is no qualifier. The introduction of the local anesthetic is not coded because it is injected only to ease the pain of the anti-inflammatory injection. The Marcaine and Fentanyl are regional anesthesia and are coded separately.

Rationale: The root operation Replacement is used to code the replacement of the lens, body part value, J, Lens, Right. The device value is J, Synthetic Substitute. The root operation Excision is used to code the vitrectomy, body part value 4, Vitreous, Right. The root operation Replacement is used to code the corneal transplant. ICD-10-PCS does not consider the replacement of the cornea to be a transplant because it is not a living organ, only a body part. This is body part value 8, Cornea, Right and device value K, Nonautologous tissue substitute, because it came from a donor.

Rationale: The root operation Other Procedures and a method of Acupuncture are used to code this procedure. The body region is H, Integumentary System and Breast. The approach is 3, Percutaneous. The method is 0, Acupuncture, and there is no qualifier.

Rationale: The index directs the coder to use the lower leg muscle for the peroneus brevis muscle. The root operation Excision is used to code the resection of the small bulge of this muscle. The body part value is T, Lower Leg Muscle, Left. The approach is open and no device or qualifier values are appropriate. The index directs the coder to use the ankle ligament and bursae (body part value R) for the anterior talofibular ligament (ATFL). The root operation Repair is used to code the reattachment of the ligament to the bone using an anchor. The approach is open and no device or qualifier values are appropriate. The below-the-knee cast is not coded separately. Casts are only coded when placed on a non-displaced fracture and therefore, the only procedure performed to stabilize a fracture.

Rationale: The root operation Excision is used to code the harvesting of the temporalis fascia graft to be used in the Supplement procedure on the tympanic membrane. The body part value for the temporalis fascia is 0, Subcutaneous Tissue and Fascia, Scalp. The approach is open. This is coded based on Guideline B3.9 that states if an autograft is obtained from a different body part in order to complete the objective of the procedure, a separate procedure is coded. The root operation Destruction is used to code the canaloplasty procedure, which is actually widening the ear canal by destroying extra temporal bone using a cutting burr (the external auditory meatus and canal are located in the temporal bone). This is not the root operation Dilation because the ear canal is not a tubular body part. The root operation Supplement is used to code the tympanoplasty because a graft is used to reinforce the tympanic membrane. The approach is open, and the device value is 7, Autologous Tissue Substitute.

Rationale: The root type Speech Assessment is used to code this videofluoroscopy of swallowing and oral function. The index is little help in finding this code. The coder must realize that speech therapy is the typical professional performing this examination. The index entry for Speech Assessment directs the coder to the F00 table. From that table, the coder can assign the type qualifier value of J, Instrumental swallowing and oral function and the equipment value of W, Swallowing.

Rationale: The root operation Destruction is used to code both the destruction of the adenoids (body part value Q) and lingual tonsil (body part value 7, Tongue based on a cross-reference in the ICD-10-PCS index). The approach for both procedures is X, External because they are visible without instruments. No device or qualifier values are appropriate.