a. Resection. Rationale: see Guideline B3.8—the entire body part is taken out b. 2 the laparoscopic cholecystectomy and the liver biopsy c. 0FT44ZZ, 0FB04ZX Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical Hepatobiliary System and Pancreas Resection Gallbladder Percutaneous Endoscopic No Device No Qualifier 0 F T 4 4 Z Z Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical Hepatobiliary System and Pancreas Excision Liver Percutaneous Endoscopic No Device Diagnostic 0 F B 0 4 Z X Case 3 a. 2 b. 0CBV8ZZ, 0CBT8ZZ Rationale: See the Index main term Excision, subterms Vocal Cord, Left, Vocal Cord, Right Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical Mouth and Throat Excision Vocal Cord, Left Via Natural or Artificial Opening, Endoscopic No Device No Qualifier 0 C B V 8 Z Z Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical Mouth and Throat Excision Vocal Cord, Right Via Natural or Artificial Opening, Endoscopic No Device No Qualifier 0 C B T 8 Z Z c. B3.2.a—multiple procedures are coded if the same root operation is performed on different body parts as defined by distinct values of the body part character. B3.11a—Inspection of a body part(s) performed in order to achieve the objective of a procedure is not coded separately.
Chapter 3 2013 Updates There are no 2013 updates for Chapter 3 1. b 3. c 5. b 7. d Which Root Operation Is It? Root Operation: Resection ICD-10-PCS Code: 0FT20ZZ Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical Hepatobiliary System and Pancreas Resection Liver, Left Lobe Open No Device No Qualifier 0 F T 2 0 Z Z 3. Root Operation: Extirpation ICD-10-PCS Code: 0TC43ZZ Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical Urinary System Extirpation Kidney Pelvis, Left Percutaneous No Device No Qualifier 0 T C 4 3 Z Z 5. Root Operation: Extraction ICD-10-PCS Code: 07DR3ZX Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical Lymphatic and Hemic Systems Extraction Bone Marrow, Iliac Percutaneous No Device Diagnostic 0 7 D R 3 Z X
7. Root Operation: Destruction ICD-10-PCS Code: 015C3ZZ Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical Peripheral Nervous System Destruction Pudendal Nerve Percutaneous No Device No Qualifier 0 1 5 C 3 Z Z 9. Root Operation: Fragmentation ICD-10-PCS Code: 0TF78ZZ Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical Urinary System Fragmentation Ureter, Left Via Natural or Artificial Opening, Endoscopic No Device No Qualifier 0 T F 7 8 Z Z Chapter 4 2013 Updates There are no 2013 updates for Chapter 4 Check Your Understanding b 3. a 5. c 7. c 9. d Which Root Operation Is It? Root Operation: Release ICD-10-PCS Code: 0DN34ZZ Section Body System Root Operation Body Part Approach Device Qualifier
Medical and Surgical Gastrointestinal System Release Esophagus, Lower Percutaneous Endoscopic No Device No Qualifier 0 D N 3 4 Z Z 3. Root Operation: Reposition ICD-10-PCS Code: 0MSN4ZZ Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical Bursae and Ligaments Reposition Knee Bursae and Ligaments, Right Percutaneous Endoscopic No Device No Qualifier 0 M S N 4 Z Z 5. Root Operation: Transfer ICD-10-PCS Code: 01X50Z4 The Anterior Interosseous nerve is not listed under the main term Transfer, Nerve. See the Body Part Index and/or the Index under the Anterior Interosseous Nerve, use Nerve, Median. Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical Peripheral Nervous System Transfer Median Nerve Open No Device Ulnar Nerve 0 1 X 5 0 Z 4 7. Root Operation: Division ICD-10-PCS Code: 0Q860ZZ Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical Lower Bones Division Upper Femur, Right Open No Device No Qualifier 0 Q 8 6 0 Z Z 9. Root Operation: Transplantation ICD-10-PCS Code: 0TY00Z0
Medical and Surgical Urinary System Transplantation Kidney, Right Open No Device Allogeneic 0 T Y 0 0 Z 0 Chapter 5 2013 Updates Which Root Operation Is It? #11 C. Change to read: What are the codes? Check Your Understanding c 3. c 5. b 7. b Which Root Operation Is It? Root Operation: Occlusion ICD-10-PCS Code: 0DL34CZ Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical Lower Veins Occlusion Gastric Vein Percutaneous No Device No Qualifier 0 6 L 2 3 Z Z 3. Root Operation: Occlusion ICD-10-PCS Code: 02L73DK Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical Heart and Great Vessels Occlusion Atrium, Left Percutaneous Intraluminal Device Left Atrial Appendage 0 2 L 7 3 D K 5. Root Operation: Supplement
System Operation Medical and Surgical Heart and Great Vessels Bypass Coronary Arteries, One Site Open Autologous Arterial Tissue Aorta 0 2 1 0 0 A W Aorta to diagonal and obtuse marginal via Left saphenous graft -021109W Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical Heart and Great Vessels Bypass Coronary Arteries, Two Sites Open Autologous Venous Tissue Aorta 0 2 1 1 0 9 W Excision of left radial artery -03BC4ZZ Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical Upper Arteries Excision Radial Artery, Left Percutaneous Endoscopic No Device No Qualifier 0 3 B C 4 Z Z Excision of left saphenous graft-06BQ4ZZ Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical Lower Veins Excision Greater Saphenous Vein, Left Percutaneous Endoscopic No Device No Qualifier 0 6 B Q 4 Z Z Chapter 6 2013 Updates Which Root Operation Is It? Change #8 to read: “A patient undergoes a female to male gender reassignment operation in which a penis is created using autografts that were previously harvested from both arms and saved in a tissue bank.”
Check Your Understanding c 3. c 5 a 7. c Which Root Operation Is It? 1. Root Operation: Repair ICD-10-PCS code: 0MQ24ZZ Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical Bursae and Ligaments Repair Shoulder and Bursae and LigamentLeft Percutaneous Endoscopic No Device No Qualifier 0 M Q 2 4 Z Z 3. Root Operation: Control ICD-10-PCS code: 0W380ZZ Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical Anatomical Regions, General Control Chest Wall Open No Device No Qualifier 0 W 3 8 0 Z Z 5. Root Operation: Fusion ICD-10-PCS code: 0SG00K1, 0SG30K1 Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical Lower Joints Fusion Lumbar Vertebral Joint Open Nonautologous Tissue Substitute Posterior Approach, Posterior Column 0 S G 0 0 K 1 Section Body System Root Operation Body Part Approach Device Qualifier
1. Answer: upper, scapula, clavicle Rationale: The body part value Forequarter describes the entire upper limb plus the scapula and clavicle. 3. Answer: d Rationale: This is a complete detachment of the 3rd day, based on the definition of amputation through the tarsal-metatarsal joint of the foot. This definition is the same as amputation at the most proximal portion of the metatarsal. 5. Answer: True Rationale: The body part value describes the body part at the start of the procedure and the qualifier describes the body part created in the surgical procedure. Procedure statement coding 1. Root: Repair; Code: 0WQ6XZ2 Rationale: This procedure involves the repair of the neck (Anatomical regions, general), rather than revision of the tracheostomy tube, therefore the root operation is Repair. The approach is X, External and the qualifier is 2, Stoma. 3. Root operation: Alteration; Code: 0Y0C3ZZ Root operation: Alteration; Code: 0Y0D3ZZ Root operation: Alteration; Code: 0W0F0ZZ Rationale: These procedures are cosmetic in nature. There are individual body part values for each thigh region (upper leg). There is a single body part value for the abdominal wall. The liposuction is performed percutaneously and the abdominoplasty is an open procedure. No devices or qualifiers are appropriate for either procedure. 5. Root: Detachment; Code: 0X6W0Z0 Rationale: Because the supernumerary digit contains bone and nail, the root operation Detachment is coded. If the supernumerary digit was composed only of skin, the root operation Destruction would be assigned. The qualifier value 0 is for a complete amputation of the little finger of the left hand. Case study coding 1. ICD-10-PCS code: 0W9900Z Rationale: Insertion of a chest tube is coded to the root operation Drainage, with a device value of 0 for a drainage device. The body part value of 9 is assigned for the pleural cavity on the right side.
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 1. 0SRC0J9, 8E0YXBZ 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. 3. Root: Acupuncture; Code: 8E0H30Z 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. Chapter 24 2013 Updates Update page 492 under the heading of “Contrast Used for the Imaging Section” by deleting the last sentence of the first paragraph. The paragraph should end with the reference to (ASHP 2011). This document is no longer available on the internet. The following is a list of low osmolar contrast media that you can use: Isovue 200, 250, 300, and 370 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 Answer Key Check Your Understanding Coding Knowledge Check 1. Plain Radiography