Which coding guideline describes the body part values for bypass procedures?
1. Refer to the 0HH table in your code book. Which of the following is an invalid PCS code?
a. 0HHPXYZ
b. 0HHT71Z
c. 0HHT0ZZ
d. 0HHW3NZ
2. Which approach value is selected for a laparoscopic appendectomy?
a. 0- open
b. 3- percutaneous
c. 4- percutaneous endoscopic
d. 8- via natural or artificial opening endoscopic
3. Which coding guideline describes the body part values for bypass procedures?
a. B3.4a
b. B3.6a
c. B3.7
d. B3.11a
4. Using the coding table below, choose the code for a Bronchoscopy. (Be sure you know how a Bronchoscopy is done and what body part is involved.)
? 0BJ14ZZ
? 0BJ08ZZ
? 0BJ04ZZ
? 0BJ07ZZ
0 Medical and Surgical
BRespiratory System
JInspection
Body Part
Character 4
Approach
Character 5
Device
Character 6
Qualifier
Character 7
0 Tracheobronchial Tree
1 Trachea
K Lung, Right
L Lung, Left
Q Pleura
T Diaphragm
0 Open
3 Percutaneous
4 Percutaneous Endoscopic
7 Via Natural or Artificial Opening
8 Via Natural or Artificial Opening, Endoscopic
X External
Z No device
Z No Qualifier
5. Using the coding table below, choose the code for Mediastinoscopy. (Be sure you know what this procedure is and what body part is involved.)
?0WJCXZZ
?0WJC4ZZ
?0WJQ7ZZ
?0WJ80ZZ
0 Medical and Surgical
W Anatomical Regions, General
J Inspection
Body Part
Character 4
Approach
Character 5
Device
Character 6
Qualifier
Character 7
0 Head
2 Face
3 Oral Cavity and Throat
4 Upper Jaw
5 Lower Jaw
6 Neck
8 Chest Wall
F Abdominal Wall
K Upper Back
L Lower Back
M Perineum, Male
N Perineum, Female
0 Open
3 Percutaneous
4 Percutaneous Endoscopic
X External
Z No device
Z No Qualifier
1 Cranial Cavity
9 Pleural Cavity, Right
B Pleural Cavity, Left
C Mediastinum
D Pericardial Cavity
G Peritoneal Cavity
H Retroperitoneum
J Pelvic Cavity
0 Open
3 Percutaneous
4 Percutaneous Endoscopic
Z No device
Z No Qualifier
P Gastrointestinal Tract
Q Respiratory Tract
R Genitourinary Tract
0 Open
3 Percutaneous
4 Percutaneous Endoscopic
7 Via Natural or Artificial Opening
8 Via Natural or Artificial Opening, Endoscopic
Z No device
Z No Qualifier
Code the following procedure statements using ICD 10 PCS codes.
One code is required for each statement. Each code is worth one point.
6.Laryngoscopy with removal of polyps on the left vocal cord ______________
7. Laparoscopic cholecystectomy (entire gallbladder removed) _______________
8. A patient with undescended testes has an open bilateral orchiopexy _____________
9. Percutaneous control of bleeding at operative site after a procedure done on the right lower arm ____________
10. Repair of sclera, right eye ________
11. Open reduction with internal fixation, fracture of right humeral shaft____________
12. Partial glossectomy, external approach ___________
13. Extracorporeal shockwave lithotripsy of a stone in the bladder neck ___________
14. Esophagoscopy ___________
15. Laparoscopic adhesiolysis to release jejunal adhesions _________
Code the following 3case studies using ICD 10 PCS codes.
Case studies are worth 5 points each, regardless of the number of codes required.
Hints and tips are in parenthesis.
Case study #1
PROCEDURE: Colonoscopy
INDICATION FOR PROCEDURE: Evaluation (diagnostic) of a patient with a history of colon polyps.
PREOPERATIVE DIAGNOSIS: Patient with a history of colon polyps.
POSTOPERATIVE DIAGNOSIS: A large polyp was found in the ileocecal valve. The polyp was removed and sent to pathology for a biopsy. Pathology results are pending at the time of this dictation.
PROCEDURE NOTE: After informed consent was obtained, the risks and benefits of the procedure were explained to the patient. The patient was placed in a left lateral decubitus position. The colonoscope (endoscope used for the colon)was passed to the cecum with adequate visualization.
The cecum appeared normal. On the ileocecal valve, there was found a 1.5 cm polyp that was removed by polypectomy by hot snare and submitted to pathology for biopsy. The remainder of the ascending colon appeared to be normal as were the transverse, descending, and sigmoid colon. The rectum has internal hemorrhoids that were left intact.
The colonoscope was withdrawn and the patient tolerated the procedure with no complications.
The code for this procedure is:
Case study #2
PROCEDURE: Laparoscopicadhesiolysis(Think about what the objective of this procedure is to determine the root operation .)
INDICATION FOR PROCEDURE: Previous pelvic surgery and personal history of ovarian cysts
PREOPERATIVE DIAGNOSIS: Pelvic pain and a history of previous pelvic surgery and ovarian cysts.
POSTOPERATIVE DIAGNOSIS: Adhesions due to prior surgery of the greater omentum to the anterior abdominal wall. No ovarian cysts were found.
PROCEDURE NOTE: A supraumbilical incision (small incision as this is laparoscopic) was made with a scalpel and elevated up with towel clamps. A long Veress needle was placed and CO2 gas was used to insufflate the abdomen and pelvis. A 10-12 trocar and sleeve were then placed and confirmed via the laparoscope.
The dense greater omental adhesions to the anterior abdominal wall were noted immediately. At that time, we were not able to see into the pelvic region. A second 5mm trocar and sleeve were placed in the left mid quadrant under direct visualization. The ligature device was then placed developing a plane between the omentum and the anterior abdominal wall.
The adhesiolysis (What is the objective of a lysis of adhesions?) took place and took approximately 25 minutes to release all of the omental adhesions from the anterior abdominal wall. The ovary was visualized with no evidence of ovarian cyst or pathology and no evidence of pelvic endometriosis. The uterus appeared normal. The procedure was terminated at this time. The ports were removed the CO2 gas allowed to escape. The incisions were closed with Vicryl suture. The patient tolerated the procedure well with no complications.
The code for this procedure is:
Case study #3
PROCEDURE: Right below the knee amputation
INDICATION FOR PROCEDURE: Gangrene of the right foot due to diabetes.
PREOPERATIVE DIAGNOSIS: Gangrene of the right foot
POSTOPERATIVE DIAGNOSIS: Gangrene of the right foot
PROCEDURE NOTE: The patient was brought to the operating suite and given general LMA anesthesia. The right foot was secluded in an isolation bag and the lower extremity circumferentially prepped and draped in its entirety.
Beginning on the right side, the skin was marked with a marking pen 4 fingerbreadths below the tibial tuberosity. (Check the anatomy for this to determine your qualifier) anteriorly with a long posterior flap. The skin was incised circumferentially and the anterior muscle was sharply divided exposing the tibia.
The tibia was cleaned with a periosteal elevator and then transected with the Stryker saw. The fibula was exposed and transected with the bone cutter and the amputation completed by sharply incising the posterior muscles. Bleeding vessels were ligated. The wound was irrigated and ultimately closed without significant tension utilizing interrupted vicryl sutures and skin staples.
The code for this procedure is:
RB
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