WIXLIB

12. Answer: 0QSG0ZZCharacterCodeSection0Body System QRootSOperationBody PartGApproach0DeviceZQualifierZExplanationMedical and SurgicalLower BonesRepositionTibia, RightOpenNo DeviceNo QualifierINDEX:Root Operation: Reposition. Index:Reduction, fracture, see reposition. Reposition,Tibia, Right (0QSG). There is no device used forthis question because no fixation device is includedin the procedure title. The device character wouldchange depending on the type of fixation device use,if any.13. Answer: ionBody PartGApproach0Device8QualifierZExplanationMedical and SurgicalHeart and Great VesselsReplacementMitral ValveOpenZooplastic TissueNo QualifierINDEX:Root Operation: Replacement. Index:Replacement, Valve, Mitral (02RG) The coder needsto complete the code with the approach (open), thedevice (porcine which is animal or zooplastic tissue)and the default “Z” for no qualifier .14. Answer: ionBody Part0Approach3DeviceZQualifierZExplanationMedical and SurgicalHeart and Great VesselsDilationCoronary Artery, One SitePercutaneousNo DeviceNo QualifierINDEX: Root Operation: Dilation. Index:Angioplasty—see Dilation, Heart and Great Vessels.Index: Dilation, artery, coronary, one site (0270)Also the option “PTCA” see Dilation, Heart andGreat Vessels (027) The coding of a PTCAprocedure depends on coronary artery lesion sites(See guideline B4.4) involved (body part), theapproach (usually percutaneous) and whether or nota stent (and what type) is used for the devicecharacter. Bifurcation for a qualifier option is toidentify when a procedure is performed at site of avessel’s bifurcation.

15. Answer: 0D5N8ZZCharacterCode ExplanationSection0Medical and SurgicalBodyDGastrointestinal SystemSystemRoot5DestructionOperationBody PartNSigmoid ColonApproach8Via Natural or ArtificialOpening EndoscopicDeviceZNo DeviceQualifierZNo QualifierINDEX:Root Operation: Destruction. Index:Fulguration—see Destruction. Destruction, colon,sigmoid (0D5N.) Usually, a procedure like thisexample is titled colonoscopy with fulguration ofpolyp. The coder must complete the code with theapproach (endoscopic via natural opening to reach acolonic polyp) and there is no option for a device ora qualifier.16. Answer: 05CD0ZZCharacterCodeSection0Body System 5RootCOperationBody PartDApproach0DeviceZQualifierZExplanationMedical and SurgicalUpper VeinsExtirpationCephalic Vein, RightOpenNo DeviceNo QualifierINDEX:Root Operation: Extirpation.Thrombectomy-see Extirpation. Index: Extirpation,Vein, Cephalic, Right (05CD) Again, the coder mustcomplete the coder with the approach (open byincision) but no options for device or qualifier.17. Answer: 0SWD0JZCharacterCodeSection0Body System SRootWOperationBody PartDApproach0DeviceJQualifierZExplanationMedical and SurgicalLower JointsRevisionKnee Joint, LeftOpenSynthetic SubstituteNo QualifierINDEX:Root Operation: Revision. Index:Revision of device in, joint, knee, left (0SWD)Coderneeds to complete 5th character for approach (open),6th character for device (joint prosthesis are metal orceramic, which are synthetic substitutes for the joint)and no option for qualifier

18. Answer: 0UDB8ZXCharacterCode ExplanationSection0Medical and SurgicalBodyUFemale dy PartBEndometriumApproach8Via Natural or ArtificialOpening EndoscopicDeviceZNo DeviceQualifierXDiagnostic20. Answer: ionBody Part4Approach8INDEX:Root Operation: Extraction. Index:Curettage—see Excision, see Extraction Theobjective of the procedure, D&C, is a curettage ofthe endometrium. A curettage is not an excisionprocedure. It is a pulling or stripping out or off all ofa body part by the use of force which is thedefinition of extraction. Extraction, Endometrium(0UDB). Hysteroscopy for the approach is anendoscopic procedure through a natural opening toreach the endometrium. Qualifier X used as theprocedure is described as diagnostic.INDEX:Root Operation: Division. Index:Esophagotomy see Division, EsophagogastricJunction (0D84). The root operation of division isdefined as cutting into a body part without drainingfluids and/or gases from the body part in order toseparate or transect a body part. Anesophagomyotomy is a procedure to cut into theesophagus muscle. The approach, an EGD, isendoscopic procedure through a natural orifice.There is no option for a device or qualifier.19. Answer: ionBody Part6ApproachXDeviceZQualifierZExplanationMedical and SurgicalUrinary SystemFragmentationUreter, RightExternalNo DeviceNo QualifierINDEX: Root Operation: Fragmentation. Index:Lithotripsy see Fragmentation, Ureter, Right (0TF6)Body part involved is the right ureter. An alternateindex entry—Extracorporeal shockwavelithotripsy—see Fragmentation. Extracorporealshock wave lithotripsy (ESWL) is the most commontype of lithotripsy. "Extracorporeal" means outsidethe body. Lithotripsy is an external procedure as theshockwaves enter through the body, not through anincision or orifice. Approach is therefore external.The code is completed using the default Z for nodevice and no qualifier.DeviceQualifierZZExplanationMedical and SurgicalGastrointestinal SystemDivisionEsophagogastric JunctionVia Natural or ArtificialOpening EndoscopicNo DeviceNo Qualifier21. Answer: 0HXKXZZCharacterCode ExplanationSection0Medical and SurgicalBodyHSkin and BreastSystemRootXTransferOperationBody PartKSkin, Right Lower LegApproachXExternalDeviceZNo DeviceQualifierZNo QualifierINDEX:Root Operation: Transfer. Index:Transfer, skin, lower leg, right (0HXKXZZ) Indexgives the coder the seven characters to verify in thecode Table. Any procedure done on skin is anexternal procedure.22. Answer: 02VQ0CZCharacterCode ExplanationSection0Medical and SurgicalBody2Heart and Great VesselsSystemRootVRestrictionOperationBody PartQPulmonary Artery, RightApproach0OpenDeviceCExtraluminal DeviceQualifierZNo Qualifier

INDEX: Root Operation: Restriction. Index:Banding—see Restriction, Artery, Pulmonary, Right(02VQ.) The root operation “restriction” is definedas partially closing an orifice or the lumen of atubular body part. A banding procedure puts adevice on a tubular body part to partially close thelumen. Approach is open as a thoracotomy. Deviceis specified in procedure title as an extraluminaldevice that is the actual banding of the vessel.Extraluminal—outside the tube/vessel.23.23. Answer: ionBody PartEApproach3DeviceDQualifierTExplanationMedical and SurgicalLower ArteriesOcclusionInternal Iliac Artery, RightPercutaneousIntraluminal DeviceUterine Artery, RightINDEX:Root Operation: Occlusion. Index:Embolization—see Occlusion, artery, internal iliac,right uterine artery, right (04LE) There is no entry inthe Index for artery, uterine. Using the Body PartKey, the uterine artery is used as the internal iliacartery for the body part character. The Device Key isused to identify that embolization coil is anintraluminal device for the device character. TheQualifier “T” identifies the uterine artery as the siteof the procedure.24. Answer: 0W4M0K0CharacterCode ExplanationSection0Medical and SurgicalBodyWAnatomical Regions, GeneralSystemRoot4CreationOperationBody PartMPerineum, MaleApproach0OpenDeviceKNonautologous TissueSubstituteQualifier0VaginaINDEX:Creation. The coder must know thedefinition of the root operations so that the rootoperation of “creation” is accessed in the Index.Index: Creation, male, should be used as it is a malepatient having the procedure. The body part of themale where the procedure is performed is theperineum. The device of tissue bank donor materialis nonautologous or other human tissue. TheQualifier identifies that a vagina is being created.25. Answer: ionBody PartVApproach0DeviceJQualifierZExplanationMedical and SurgicalSkin and BreastAlterationBreast, BilateralOpenSynthetic SubstituteQualifierINDEX:Root Operation: Alteration. Coder mustrecognize this is a cosmetic procedure, therefore, theroot operation is alteration. Index: Alteration, breast,bilateral (0H0V) The silicone implants are thedevice which is a synthetic substitute.26. Answer: 00HV3MZCharacterCode ExplanationSection0Medical and SurgicalBody0Central Nervous SystemSystemRootHInsertionOperationBody PartVSpinal CordApproach3PercutaneousDeviceMNeurostimulator LeadQualifierZNo QualifierINDEX: Root Operation: Insertion. Index: Insertionof device in, spinal cord (00HV). The device is aneurostimulator which is inserted into lumbar spinalcord by percutaneous approach.27. Answer: 0UUG0JZCharacterCode ExplanationSection0Medical and SurgicalBodyUFemale Reproductive SystemSystemRootUSupplementOperationBody PartGVaginaApproach0OpenDeviceJSynthetic SubstituteQualifierZNo QualifierINDEX:Root Operation: Supplement. Index:Colporrhaphy see Repair, Vagina (0UQG) Whenreviewing this table, coder will note there is nodevice character to identify the mesh used. So this is

not the correct root operation. The definition ofsupplement is putting in or on biological or syntheticmaterial that physically reinforces and/or augmentsthe function of a portion of a body part. Theinsertion of mesh is a “supplement” procedure thatreinforces the structure of the body part. The Indexentry to be used is Supplement, vagina (0UUG).Mesh is a synthetic product.28. Answer: 0B21XFZCharacterCode ExplanationSection0Medical and SurgicalBodyBRespiratory SystemSystemRoot2ChangeOperationBody Part1TracheaApproachXExternalDeviceFTracheostomy DeviceQualifierZNo QualifierINDEX:Root Operation: Change. Index:Exchange see Change device in, trachea (0B21). Anexchange procedure is removing and reinserting thesame or similar device into the same location. Atracheostomy tube exchange involved a device in thetrachea. The approach is external the tracheostomyopening is accessed directly at the skin level.29. Answer: ionBody Part0Approach0DeviceZQualifierZExplanationMedical and SurgicalCentral Nervous SystemMapBrainOpenNo DeviceNo QualifierINDEX:Root Operation: Map. Index: Map,brain (00K0). The approach is open as described bythe craniotomy. There is no device left in the bodyafter the procedure and no qualifier listed on thecode table.30. Answer: 0W3G0ZZCharacterCode ExplanationSection0Medical and SurgicalBodyWAnatomical Regions,SystemGeneralRoot3ControlOperationBody PartGPeritoneal CavityApproach0OpenDeviceZNo DeviceQualifierZNo QualifierINDEX:Root Operation: Control. The procedureis identified as a control of postoperative bleeding.Index: Control, postprocedural bleeding in,peritoneal cavity (0W3G). The approach is open asdescribed by laparotomy. The body part where theprocedure is performed is the peritoneal cavitywhere the bleeding occurred.

Chapter 3Introduction to theUniform Hospital Discharge Data Setand Official ICD-10-CM CodingGuidelinesReview Exercises: Chapter 31. To establish a minimum common core of data tobe collected on individual acute care short termhospital discharges in Medicare and Medicaidprograms. UHDDS sought to improve the uniformityand comparability of hospital discharge data. Allnon-outpatient settings including acute care, shortterm care, long term care, and psychiatric hospitals,home health agencies, rehabilitation facilities, andnursing homes.2. The condition established after study to bechiefly responsible for occasioning the admission ofthe patient to the hospital for care.3. Conditions that coexist at the time of admission,that develop subsequently, or that affect the treatmentreceived and/or the length of stay. Diagnoses are tobe excluded that relate to an earlier episode that hasno bearing on the current hospital stay.4. . A complication is an additional diagnosis thatdescribes a condition arising after the beginning ofthe hospital observation and treatment and thenmodifying the course of the patient’s illness or themedical care required. A comorbidity is an additionaldiagnosis that describes a preexisting condition thatbecause of its presence with a specific principaldiagnosis will likely cause an increase in the patient’slength of stay in the hospital.5 . Grand total of 22.18 Diagnosis codes 3 E codes 1 admittingdiagnosis code6 . 6 procedure codestwo diagnoses equally meet the definition ofprincipal diagnosis.10 .Principal diagnosis could be either acutepancreatitis or acute cholangitis as both areunconfirmed diagnosis and could explain thepatient’s symptoms. Because there are no specificsymptoms noted, either acute pancreatitis or acutecholangitis may be listed as the principal diagnosis.11 .Principal diagnosis is left lower quadrantabdominal pain. The diagnoses of ruptured ovariancyst and acute salpingitis are coded as additionaldiagnoses.12 .Principal diagnosis is osteoarthritis of knee.Additional codes for hypertensive heart disease andcode for surgical or other procedure not carried outbecause of contraindication, would be assigned.13 .Principal diagnosis is postoperative woundinfection. An additional diagnosis for diverticulitis isassigned.14 .Principal diagnosis is viral pneumonia.15 .Principal diagnosis is status asthmaticus16 .Principal diagnosis is orthostatichypotension. An additional diagnosis code forcataract is also assigned. The procedure of thecataract extraction is also coded.17 .The other diagnoses of cholelithiasis andtype II diabetes are coded. The history of pneumoniaand status post bunionectomy are unrelated to thishospital stay, are historical events, and therefore notcoded.18 .The other diagnoses of hypertension andbenign prostatic hypertrophy are coded. No otherdiagnoses codes for the findings from the laboratoryreports should be assigned without asking thephysician if the abnormal findings are significant.7 . Principal diagnosis seizure19 .In addition to the gastritis, both the acuteduodenitis and acute pancreatitis should be coded.8 . Principal diagnosis could be either acutepyelonephritis or acute cystitis as there are interrelated conditions (same ICD-9-CM chapter) andboth were treated during the hospital stay.20 .The urinary retention would be reported with“N” for no, condition not present on admission.9 . Principal diagnosis could be either acuteexacerbation of COPD or acute low back pain as the

Chapter 4Certain Infectious and ParasiticDiseasesReview Exercises: Chapter 41.N39.0, Infection, urinary tractB96.4, Infection, bacterial, NOS, as cause ofdisease classified elsewhere, Proteus(mirabilis)The “Use additional code’ note under N39.0instructs the coder to an additional code(B95–B97) to identify the infectious agent.2.A04.7, Colitis, Clostridium difficileZ16.24, Resistance, to multiple drugs(MDRO) antibioticsICD-10-CM provides a code to identify drugresistant organisms (Z16). The “useadditional code” note is found at thebeginning of Chapter 1.3.A02.9, Poisoning, food, bacterial—seeIntoxication, foodborne, due to SalmonellaAnother entry is Poisoning, food, due to,Salmonella.Food poisoning is classified to Chapter 1,Certain infectious and parasitic disease(A00–B99). If gastroenteritis is documented,then the code would change to A02.0.4.A56.11, Salpingitis, chlamydial5.B20, AIDSC46.0 Sarcoma, Kaposi's, skin (multiple)6.A41.81 Sepsis, EnterococcusK57.40 Diverticulitis, intestine, large,with small intestine, with perforation7.A41.3 Sepsis, Haemophilus influenzaeR65.21 Sepsis, severe, with septic shockN17.9 Failure, renal acute8.A37.01 Whooping cough, due toBordetella, pertussis, with pneumonia9.B16,2 Hepatitis, B, acute, with, hepaticcoma10.B37.81, Esophagitis, candidalA combination code exists in ICD-10-CM toidentify the myotic condition of candidiasisoccurring in the esophagus and causing anesophagitis condition.11. PROCEDURE: Insertion of multilumen centralvenous catheter into the right subclavian vein forintravenous infusion by percutaneous approachCharacterCode ExplanationSection0Medical and SurgicalBody5Upper VeinsSystemRootHInsertionOperationBody Part5Subclavian Vein, RightApproach3PercutaneousDevice3Infusion DeviceQualifierZNo QualifierINDEX: Insertion of device in, vein, subclavian,right 05H512. PROCEDURE: Exploratory laparotomy andsmall-bowel resection of 50 cm portion of thejejunum with side-to-side, functional end-to-endsewn anastomosis of the jejunum. The patient hasperitonitis and a twisted nonviable small bowel.CharacterCode ExplanationSection0Medical and SurgicalBodyDGastrointestinal SystemSystemRootBExcisionOperationBody PartAJejunumApproach0OpenDeviceZNo DeviceQualifierZNo QualifierINDEX: Excision, jejunum 0DBA. The physicianstates resection but according to the definition of theroot operations resection and excision, this operationis an excision because only a portion of the smallbowel/jejunum. The approach is open as stated byexploratory laparotomy. Anastomosis should not beassigned separately. New coding guideline in 2013.B3.1b Components of a procedure specified in theroot operation definition and explanation are notcoded separately. Procedural steps necessary toreach the operative site and close the operative site,including anastomosis of a tubular body part, arealso not coded separately. Example: Resection of ajoint as part of a joint replacement procedure isincluded in the root operation definition ofReplacement and is not coded separately.Laparotomy performed to reach the site of an openliver biopsy is not coded separately. In a resection of

sigmoid colon with anastomosis of descending colonto rectum, the anastomosis is not coded separately.13. PROCEDURE: Insertion of venous accessdevice/port percutaneously into the subclavian veinadvanced to the superior vena cava with a pocket forthe port placed in the subcutaneous tissue of thechest wall for chemotherapy to treat coloncarcinoma. An incision is made to create the pocket.CharacterCo

the ICD-10-PCS guideline for fusion procedures of the spine, B3.10a: The body part coded for a spinal vertebral joint(s) rendered immobile by a spinal fusion procedure is classified by the level of the spine (e.g. thoracic). There are distinct body part values for a single vertebral joint and for multiple vertebral joints at each spinal level.