AC200512 AnswerKey 1 Coding 2 Basic ICD-10-CMPCS Coding

AC AnswerKey 1 Coding 2 Basic ICD-10-CMPCS Coding Basic ICD-10-CM/PCS Coding 2013 Edition Answer Key Lou Ann Schraffenberger, MBA, RHIA, CCS, CCS-P, FAHIMA Answer Key The answer key includes the correct ICD-10-CM/PCS codes and the Alphabetic Index entry used to locate each code. Chapter 1 Introduction to ICD-10-CM Exercise 1.1 1. N63 Mass, breast 2. N13.30 Hydronephrosis (primary) 3. J34.2 Deviated, nasal septum 4. R59.0 Adenopathy, inguinal 5. I25.10 Disease, arteriosclerotic—see Disease, heart, ischemic, atherosclerotic. Arteriosclerotic heart—see Arteriosclerosis, coronary (artery) 6. G44.209 Headache, tension 7. K85.9 Pancreatitis (suppurative) 8. K00.6 Eruption, tooth abnormal (premature) 9. I33.0 Endocarditis, infectious 10. I08.0 Endocarditis, mitral with aortic (valve) disease, active or acute Exercise 1.2 1. Nonessential modifier = congenital Q67.8 Distortion (congenital) chest (wall) 2. Nonessential modifier=acute K57.32 Diverticulitis (acute) intestine, large 3. Nonessential modifier = bleeding K64.4 Hemorrhoids external 4. Nonessential modifier=cardiac R01.0 Murmur (cardiac) functional 5. Nonessential modifier=chronic J32.0 Sinusitis (chronic) maxillary Exercise 1.3 1. Main term=Endomyometritis N71.0 Endomyometritis—see Endometritis, acute 2. Main term=Metrorrhexis N85.8 Metrorrhexis—see Rupture, uterus, nontraumatic 3. Main term=Osteoarthrosis M19.019 Osteoarthrosis—see also Osteoarthritis, shoulder, M19.01- (unspecified = M19.019) 4. Main term=Prolapse M50.20 Prolapse—see Displacement, intervertebral disc, cervical 5. Main term=Stenosis N88.2 Stenosis, endocervical—see Stenosis cervix Exercise 1.4 1. A41.9 Sepsis NOS 2. A49.8 Infection, bacteroides NEC 3. I31.9 Pericarditis (with effusion) 4. B08.3 Disease, fifth Tabular List—B08.3—Erythema infectiosum [fifth disease] 5. Dementia, with, Lewy bodies G31.83 [F02.80] See the "Use additional code" note under category G31 Use additional code to identify dementia with behavioral disturbance (F02.81) Use additional code to identify dementia without behavioral disturbance (F02.80) Exercise 1.5 1. Intrahepatic bile duct 2. Diabetes mellitus arising in pregnancy Gestational diabetes mellitus 3. Anorexia nervosa 4. Blackout, Fainting, Vasovagal attack 5. Diverticulum of appendix Exercise 1.6 1. I85.11 Varix, esophagus, in, cirrhosis of liver, bleeding 2. N39.0 Infection, urinary (tract) Use additional code (B95–B97) to identify infectious agent B96.20 Infection, Escherichia coli as cause of disease classified elsewhere 3. K26.0 Ulcer, duodenum, acute, with hemorrhage 4. P61.2 Anemia, due to, prematurity 5. Z04.1 Examination, following, motor vehicle accident Review Exercises: Chapter 1 1. K35.2 Appendicitis, acute, with perforation 2. J15.4 Pneumonia, streptococcal NEC 3. R07.2 Pain, chest, precordial 4. I26.09 Cor, pulmonale, acute 5. M19.071 Osteoarthrosis—see Osteoarthritis, primary, ankle, right 6. E05.20 Goiter, nodular, toxic 7. Q89.2 Extra—see Accessory, thyroid 8. K55.21 Angiodysplasia (colon) with bleeding 9. J20.9 Tracheobronchitis—see also Bronchitis, acute 10. I25.119 Disease, heart, arteriosclerotic— see Disease, heart, ischemic, atherosclerotic with angina pectoris—see Arteriosclerosis, coronary (artery) native vessel with angina pectoris 11. M32.14 Nephritis, due to, systemic lupus erythematosus 12. Z34.02 Prenatal, care, normal first pregnancy—see Pregnancy, normal, first, second trimester 13. S72.142A Fracture, femur, upper end, intertrochanteric, left The coder must see the Tabular List for assignment of the left side and the seventh character “A” for the closed fracture, initial encounter to identify the encounter. 14. A59.02 Prostatitis, trichomonal 15. I63.239 Occlusion, artery, carotid, with cerebral infarction I10 Hypertension (essential) 16. B17.11, Hepatitis, C, acute, with hepatic coma 17. C91.01, Leukemia, acute lymphoblastic, see Tabular List for sixth character for in remission 18. D3A.020, Tumor, carcinoid, benign, appendix 19. N40.1, Enlarged, prostate, with lower urinary tract symptoms (urinary obstruction) N13.8 verified in Tabular List under code N40.1 N13.8 Obstruction, urinary, specified. Inclusion notes under N13.8 state urinary obstruction due to specified cause and there is a “code first” note present to code the causal condition such as enlarge prostate Corrected from Alphabetic Index: N13.9, Obstruction, urinary 20. Z85.3, History, personal, malignant neoplasm (of), breast Chapter 2 Introduction to ICD-10-PCS Review Exercises: Chapter 2 1. Answer: 0DJO8ZZ Character Explanation Section Medical and Surgical Body Syst em Gastrointestinal System Root Ope ratio n Inspection Body Part Upper Intestinal Tract Approach Via Natural or Artificial Opening Endoscopic Device No Device Qualifier No Qualifier INDEX: Root Operation: Inspection. Index: Esophagogastroduodenoscopy (0DJ08ZZ) In this example, the complete seven character code is listed in the Index. The code still must be confirmed using the code Tables. EGD is an inspection procedure when no other procedures, such as a biopsy or excision, are performed with the EGD. Body part inspected is the upper intestinal tract. Approach is through the mouth so “via natural or artificial opening endoscopic” is the choice for this procedure. 2. Answer: 0HBU0ZZ Character Explanation Section Medical and Surgical Body System Skin and Breast Root Oper ation Excision Body Part Breast, Left Approach Open Device No Device Qualifier No Qualifier INDEX: When consulting the Index, the main term Mastectomy has two subterms: see Excision, Skin and Breast and see Resection, Skin and Breast. Since only part of the breast was removed, the root operation is Excision. 3. Answer: 041L0KL CharacteCr ode Explanation Section Medical and Surgical Body Syste m Lower Arteries Root Oper ation Bypass Body Part Femoral Artery, Left Approach Open Device Nonautologous Tissue Substitute Qualifier Popliteal Artery INDEX: When consulting the Index, the main term Bypass, subterm Artery, Femoral produced the root operation table of 041. According to ICD-10-PCS guideline B3.6a.Bypass procedures: Bypass procedures are coded by identifying the body part bypassed “from” and the body part bypassed “to”. The fourth character body part specifies the body part bypassed from, and the qualifier specifies the body part bypassed to. In this example, the bypass was “from” the femoral artery “to” the popliteal artery. A cadaver vein graft is the device identified as nonautologous (from another human than patient) tissue substitute. 4. Answer: 0UN24ZZ CharacterCode Explanation Section Medical and Surgical Body Syste m Female Reproductive System Root Opera tion Release Body Part Ovaries, Bilateral Approach Percutaneous Endoscopic Device No Device Qualifier No Qualifier INDEX: Lysis see Release. Release, Ovaries, Bilateral (0UN2) Definition of release in ICD10-PCS is freeing a body part from an abnormal physical constraint which also describes a procedure identified as lysis. Two codes are required for this procedure as the same root operation is performed on different body parts as defined by distinct values of the body part character for the root operation “release.” Laparoscopy is an approach that is percutaneous endoscopic Answer: 0UN74ZZ Character Code Explanation Section 0 Medical and Surgical Body System U Female Reproductive System Root Operation N Release Body Part 7 Fallopian Tubes, Bilateral Approach 4 Percutaneous Endoscopic Device Z No Device Qualifier Z No Qualifier INDEX: Lysis see Release. Release, Fallopian Tubes (0UN7) 5. Answer: 0SG10A1 Character Code Explanation Section 0 Medical and Surgical Body System S Lower Joints Root Operation G Fusion Body Part 1 Lumbar Vertebral Joints, 2 or more Approach 0 Open Device A Interbody Fusion Device Qualifier 1 Posterior Approach, Posterior Column INDEX: Root operation is fusion. Index: Fusion, lumbar vertebrae 2 or more (0SG1). According to 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. According to guideline B3.10.c if an interbody fusion device is used to render the joint immobile (alone or containing other material like bone graft), the procedure is coded with the device value Interbody Fusion Device. The qualifier identifies the combination of the approach and the column. 6. Answer: 0TP98DZ Character Code Explanation Section 0 Medical and Surgical Body System T Urinary System Root Operation P Removal Body Part 9 Ureter Approach 8 Via Natural or Artificial Opening Endoscopic Device D Intraluminal Device Qualifier Z No Qualifier INDEX: Root Operation: Removal. Index: Removal of device from, Ureter (0TP9) The objective of the procedure was to take the stent out of the ureter which matches the definition of “removal” to take out of off a device from a body part. The approach is by cystoscopy or via natural or artificial opening (urethra) endoscopic. A stent is an intra-luminal device which are devices placed inside tubular body parts. 7. Answer: 0XMJ0ZZ Character Code Explanation Section 0 Medical and Surgical Body System X Anatomical Region, Upper Extremities Root Operation M Reattachment Body Part J Hand, Right Approach 0 Open Device Z No Device Qualifier Z No Qualifier INDEX: Root Operation: Reattachment. Index: Reattachment, Hand, Right (0XMJ0ZZ) Index provides a specific code for this operation. The only variable on the Table is the body part being reattached. 8. Answer: 0W9G3ZX Character Code Explanation Section 0 Medical and Surgical Body System W Anatomical Regions, General Root Operation 9 Drainage Body Part G Peritoneal Cavity Approach 3 Percutaneous Device Z No Device Qualifier X Diagnostic INDEX: Root Operation: Drainage Index: Paracentesis, Peritoneal Cavity see Drainage, Peritoneal Cavity (0W9G) The Index includes the procedure of paracentesis to send the coder directly to the correct coding Table. The approach is described as percutaneous and the procedure is identified as “diagnostic” so that the qualifier “X” is used. 9. Answer: 0Y6M0Z9 Character Code Explanation Section 0 Medical and Surgical Body System Y Anatomical Region, Lower Extremities Root Operation 6 Detachment Body Part M Foot, Right Approach 0 Open Device Z No Device Qualifier 9 Partial 1st Ray INDEX: Amputation—see Detachment. Root Operation: Detachment. Index: Detachment, Foot, Right (0Y6M0Z). The Index gives the coder everything except character 7 for the qualifier. The choices for the qualifiers listed are complete, complete 1st thought 5th ray, partial and partial 1st thought 5th ray. Complete is defined as amputation through the carpometacarpal (hand) or through tarsal-metatarsal (foot). Partial is amputation anywhere along the shaft or head of the metacarpal (hand) or metatarsal (foot). The fingers or toes are 1st thought 5th rays. In this example, the right big toe is the 1st ray. Transmetatarsal is a partial amputation. The definition of the detachment qualifiers are included in the ICD-10-PCS Reference Manual, which can be found as a download at 3-ICD-10-PCS-GEM 10. Answer: 0TY10Z0 Character Code Explanation Section 0 Medical and Surgical Body System T Urinary System Root Operation Y Transplantation Body Part 1 Kidney, Left Approach 0 Open Device Z No Device Qualifier 0 Allogeneic INDEX: Root Operation: Transplantation. Index: Transplant, Kidney, Left (0TY10Z) The Index gives six characters leaving the coder to select the qualifier to identify the type of transplant. The ICD-10-PCS Reference Manual describes transplantation as “allogeneic” for a human donor, “syngeneic” for identical twin donor, and “zooplastic” for animal as the source of the organ. 11. Answer: 0DQE0ZZ Character Code Explanation Section 0 Medical and Surgical Body System D Gastrointestinal System Root Operation Q Repair Body Part E Large Intestine Approach 0 Open Device Z No Device Qualifier Z No Qualifier INDEX: Root Operation: Repair. Index: Repair, Intestine, Large (0DQE) The term “repair” is defined as restoring to the extent possible, a body part to its normal anatomic structure and function. Often the term “repair” involves a suture repair which needs to be confirmed in the operative report. The Index includes the term “Suture, laceration repair, see Repair.” If the operative report described the location more precisely, the body part character could change. 12. Answer: 0QSG0ZZ Character Code Explanation Section 0 Medical and Surgical Body System Q Lower Bones Root Operation S Reposition Body Part G Tibia, Right Approach 0 Open Device Z No Device Qualifier Z No Qualifier INDEX: Root Operation: Reposition. Index: Reduction, fracture, see reposition. Reposition, Tibia, Right (0QSG). There is no device used for this question because no fixation device is included in the procedure title. The device character would change depending on the type of fixation device use, if any. 13. Answer: 02RG08Z Character Code Explanation Section 0 Medical and Surgical Body System 2 Heart and Great Vessels Root Operation R Replacement Body Part G Mitral Valve Approach 0 Open Device 8 Zooplastic Tissue Qualifier Z No Qualifier INDEX: Root Operation: Replacement. Index: Replacement, Valve, Mitral (02RG) The coder needs to complete the code with the approach (open), the device (porcine which is animal or zooplastic tissue) and the default “Z” for no qualifier . 14. Answer: 02703ZZ Character Code Explanation Section 0 Medical and Surgical Body System 2 Heart and Great Vessels Root Operation 7 Dilation Body Part 0 Coronary Artery, One Site Approach 3 Percutaneous Device Z No Device Qualifier Z No Qualifier INDEX: 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 and Great Vessels (027) The coding of a PTCA procedure depends on coronary artery lesion sites (See guideline B4.4) involved (body part), the approach (usually percutaneous) and whether or not a stent (and what type) is used for the device character. Bifurcation for a qualifier option is to identify when a procedure is performed at site of a vessel’s bifurcation. 15. Answer: 0D5N8ZZ Character Code Explanation Section 0 Medical and Surgical Body System D Gastrointestinal System Root Operation 5 Destruction Body Part N Sigmoid Colon Approach 8 Via Natural or Artificial Opening Endoscopic Device Z No Device Qualifier Z No Qualifier INDEX: Root Operation: Destruction. Index: Fulguration—see Destruction. Destruction, colon, sigmoid (0D5N.) Usually, a procedure like this example is titled colonoscopy with fulguration of polyp. The coder must complete the code with the approach (endoscopic via natural opening to reach a colonic polyp) and there is no option for a device or a qualifier. 16. Answer: 05CD0ZZ Character Code Explanation Section 0 Medical and Surgical Body System 5 Upper Veins Root Operation C Extirpation Body Part D Cephalic Vein, Right Approach 0 Open Device Z No Device Qualifier Z No Qualifier INDEX: Root Operation: Extirpation. Thrombectomy-see Extirpation. Index: Extirpation, Vein, Cephalic, Right (05CD) Again, the coder must complete the coder with the approach (open=by incision) but no options for device or qualifier. 17. Answer: 0SWD0JZ Character Code Explanation Section 0 Medical and Surgical Body System S Lower Joints Root Operation W Revision Body Part D Knee Joint, Left Approach 0 Open Device J Synthetic Substitute Qualifier Z No Qualifier INDEX: Root Operation: Revision. Index: Revision of device in, joint, knee, left (0SWD)Coder needs to complete 5th character for approach (open), 6th character for device (joint prosthesis are metal or ceramic, which are synthetic substitutes for the joint) and no option for qualifier 18. Answer: 0UDB8ZX Character Code Explanation Section 0 Medical and Surgical Body System U Female Reproductive System Root Operation D Extraction Body Part B Endometrium Approach 8 Via Natural or Artificial Opening Endoscopic Device Z No Device Qualifier X Diagnostic INDEX: Root Operation: Extraction. Index: Curettage—see Excision, see Extraction The objective of the procedure, D&C, is a curettage of the endometrium. A curettage is not an excision procedure. It is a pulling or stripping out or off all of a body part by the use of force which is the definition of extraction. Extraction, Endometrium (0UDB). Hysteroscopy for the approach is an endoscopic procedure through a natural opening to reach the endometrium. Qualifier X used as the procedure is described as diagnostic. 19. Answer: 0TF6XZZ Character Code Explanation Section 0 Medical and Surgical Body System T Urinary System Root Operation F Fragmentation Body Part 6 Ureter, Right Approach X External Device Z No Device Qualifier Z No Qualifier INDEX: Root Operation: Fragmentation. Index: Lithotripsy see Fragmentation, Ureter, Right (0TF6) Body part involved is the right ureter. An alternate index entry—Extracorporeal shockwave lithotripsy—see Fragmentation. Extracorporeal shock wave lithotripsy (ESWL) is the most common type of lithotripsy. "Extracorporeal" means outside the body. Lithotripsy is an external procedure as the shockwaves enter through the body, not through an incision or orifice. Approach is therefore external. The code is completed using the default Z for no device and no qualifier. 20. Answer: 0D848ZZ Character Code Explanation Section 0 Medical and Surgical Body System D Gastrointestinal System Root Operation B Division Body Part 4 Esophagogastric Junction Approach 8 Via Natural or Artificial Opening Endoscopic Device Z No Device Qualifier Z No Qualifier INDEX: Root Operation: Division. Index: Esophagotomy see Division, Esophagogastric Junction (0D84). The root operation of division is defined as cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part. An esophagomyotomy is a procedure to cut into the esophagus muscle. The approach, an EGD, is endoscopic procedure through a natural orifice. There is no option for a device or qualifier. 21. Answer: 0HXKXZZ Character Code Explanation Section 0 Medical and Surgical Body System H Skin and Breast Root Operation X Transfer Body Part K Skin, Right Lower Leg Approach X External Device Z No Device Qualifier Z No Qualifier INDEX: Root Operation: Transfer. Index: Transfer, skin, lower leg, right (0HXKXZZ) Index gives the coder the seven characters to verify in the code Table. Any procedure done on skin is an external procedure. 22. Answer: 02VQ0CZ Character Code Explanation Section 0 Medical and Surgical Body System 2 Heart and Great Vessels Root Operation V Restriction Body Part Q Pulmonary Artery, Right Approach 0 Open Device C Extraluminal Device Qualifier Z No Qualifier INDEX: Root Operation: Restriction. Index: Banding—see Restriction, Artery, Pulmonary, Right (02VQ.) The root operation “restriction” is defined as partially closing an orifice or the lumen of a tubular body part. A banding procedure puts a device on a tubular body part to partially close the lumen. Approach is open as a thoracotomy. Device is specified in procedure title as an extraluminal device that is the actual banding of the vessel. Extraluminal—outside the tube/vessel.23. 23. Answer: 04LE3DT Character Code Explanation Section 0 Medical and Surgical Body System 4 Lower Arteries Root Operation L Occlusion Body Part E Internal Iliac Artery, Right Approach 3 Percutaneous Device D Intraluminal Device Qualifier T Uterine Artery, Right INDEX: Root Operation: Occlusion. Index: Embolization—see Occlusion, artery, internal iliac, right uterine artery, right (04LE) There is no entry in the Index for artery, uterine. Using the Body Part Key, the uterine artery is used as the internal iliac artery for the body part character. The Device Key is used to identify that embolization coil is an intraluminal device for the device character. The Qualifier “T” identifies the uterine artery as the site of the procedure. 24. Answer: 0W4M0K0 Character Code Explanation Section 0 Medical and Surgical Body System W Anatomical Regions, General Root Operation 4 Creation Body Part M Perineum, Male Approach 0 Open Device K Nonautologous Tissue Substitute Qualifier 0 Vagina INDEX: Creation. The coder must know the definition of the root operations so that the root operation of “creation” is accessed in the Index. Index: Creation, male, should be used as it is a male patient having the procedure. The body part of the male where the procedure is performed is the perineum. The device of tissue bank donor material is nonautologous or other human tissue. The Qualifier identifies that a vagina is being created. 25. Answer: 0H0V0JZ Character Code Explanation Section 0 Medical and Surgical Body System H Skin and Breast Root Operation 0 Alteration Body Part V Breast, Bilateral Approach 0 Open Device J Synthetic Substitute Qualifier Z Qualifier INDEX: Root Operation: Alteration. Coder must recognize this is a cosmetic procedure, therefore, the root operation is alteration. Index: Alteration, breast, bilateral (0H0V) The silicone implants are the device which is a synthetic substitute. 26. Answer: 00HV3MZ Character Code Explanation Section 0 Medical and Surgical Body System 0 Central Nervous System Root Operation H Insertion Body Part V Spinal Cord Approach 3 Percutaneous Device M Neurostimulator Lead Qualifier Z No Qualifier INDEX: Root Operation: Insertion. Index: Insertion of device in, spinal cord (00HV). The device is a neurostimulator which is inserted into lumbar spinal cord by percutaneous approach. 27. Answer: 0UUG0JZ Character Code Explanation Section 0 Medical and Surgical Body System U Female Reproductive System Root Operation U Supplement Body Part G Vagina Approach 0 Open Device J Synthetic Substitute Qualifier Z No Qualifier INDEX: Root Operation: Supplement. Index: Colporrhaphy see Repair, Vagina (0UQG) When reviewing this table, coder will note there is no device character to identify the mesh used. So this is not the correct root operation. The definition of supplement is putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part. The insertion of mesh is a “supplement” procedure that reinforces the structure of the body part. The Index entry to be used is Supplement, vagina (0UUG). Mesh is a synthetic product. 28. Answer: 0B21XFZ Character Code Explanation Section 0 Medical and Surgical Body System B Respiratory System Root Operation 2 Change Body Part 1 Trachea Approach X External Device F Tracheostomy Device Qualifier Z No Qualifier INDEX: Root Operation: Change. Index: Exchange see Change device in, trachea (0B21). An exchange procedure is removing and reinserting the same or similar device into the same location. A tracheostomy tube exchange involved a device in the trachea. The approach is external the tracheostomy opening is accessed directly at the skin level. 29. Answer: 00K00ZZ Character Code Explanation Section 0 Medical and Surgical Body System 0 Central Nervous System Root Operation K Map Body Part 0 Brain Approach 0 Open Device Z No Device Qualifier Z No Qualifier INDEX: Root Operation: Map. Index: Map, brain (00K0). The approach is open as described by the craniotomy. There is no device left in the body after the procedure and no qualifier listed on the code table. 30. Answer: 0W3G0ZZ Character Code Explanation Section 0 Medical and Surgical Body System W Anatomical Regions, General Root Operation 3 Control Body Part G Peritoneal Cavity Approach 0 Open Device Z No Device Qualifier Z No Qualifier INDEX: Root Operation: Control. The procedure is identified as a control of postoperative bleeding. Index: Control, postprocedural bleeding in, peritoneal cavity (0W3G). The approach is open as described by laparotomy. The body part where the procedure is performed is the peritoneal cavity where the bleeding occurred. Chapter 3 Introduction to the Uniform Hospital Discharge Data Set and Official ICD-10-CM Coding Guidelines Review Exercises: Chapter 3 1. To establish a minimum common core of data to be collected on individual acute care short term hospital discharges in Medicare and Medicaid programs. UHDDS sought to improve the uniformity and comparability of hospital discharge data. All non-outpatient settings including acute care, short term care, long term care, and psychiatric hospitals, home health agencies, rehabilitation facilities, and nursing homes. 2. The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. 3. Conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses are to be excluded that relate to an earlier episode that has no bearing on the current hospital stay. 4. . A complication is an additional diagnosis that describes a condition arising after the beginning of the hospital observation and treatment and then modifying the course of the patient’s illness or the medical care required. A comorbidity is an additional diagnosis that describes a preexisting condition that because of its presence with a specific principal diagnosis will likely cause an increase in the patient’s length of stay in the hospital. 5 . Grand total of 22. 18 Diagnosis codes + 3 E codes + 1 admitting diagnosis code 6 . 6 procedure codes 7 . Principal diagnosis = seizure 8 . Principal diagnosis could be either acute pyelonephritis or acute cystitis as there are interrelated conditions (same ICD-9-CM chapter) and both were treated during the hospital stay. 9 . Principal diagnosis could be either acute exacerbation of COPD or acute low back pain as the two diagnoses equally meet the definition of principal diagnosis. 10 . Principal diagnosis could be either acute pancreatitis or acute cholangitis as both are unconfirmed diagnosis and could explain the patient’s symptoms. Because there are no specific symptoms noted, either acute pancreatitis or acute cholangitis may be listed as the principal diagnosis. 11 . Principal diagnosis is left lower quadrant abdominal pain. The diagnoses of ruptured ovarian cyst and acute salpingitis are coded as additional diagnoses. 12 . Principal diagnosis is osteoarthritis of knee. Additional codes for hypertensive heart disease and code for surgical or other procedure not carried out because of contraindication, would be assigned. 13 . Principal diagnosis is postoperative wound infection. An additional diagnosis for diverticulitis is assigned. 14 . Principal diagnosis is viral pneumonia. 15 . Principal diagnosis is status asthmaticus 16 . Principal diagnosis is orthostatic hypotension. An additional diagnosis code for cataract is also assigned. The procedure of the cataract extraction is also coded. 17 . The other diagnoses of cholelithiasis and type II diabetes are coded. The history of pneumonia and status post bunionectomy are unrelated to this hospital stay, are historical events, and therefore not coded. 18 . The other diagnoses of hypertension and benign prostatic hypertrophy are coded. No other diagnoses codes for the findings from the laboratory reports should be assigned without asking the physician if the abnormal findings are significant. 19 . In addition to the gastritis, both the acute duodenitis and acute pancreatitis should be coded. 20 . The urinary retention would be reported with “N” for no, condition not present on admission. Chapter 4 Certain Infectious and Parasitic Diseases Review Exercises: Chapter 4 1. N39.0, Infection, urinary tract B96.4, Infection, bacterial, NOS, as cause of disease classified elsewhere, Proteus (mirabilis) The “Use additional code’ note under N39.0 instructs the coder to an additional code (B95–B97) to identify the infectious agent. 2. A04.7, Colitis, Clostridium difficile Z16.24, Resistance, to multiple drugs (MDRO) antibiotics ICD-10-CM provides a code to identify drug resistant organisms (Z16). The “use additional code” note is found at the beginning of Chapter 1. 3. A02.9, Poisoning, food, bacterial—see Intoxication, foodborne, due to Salmonella Another 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, chlamydial 5. B20, AIDS C46.0 Sarcoma, Kaposi's, skin (multiple) 6. A41.81 Sepsis, Enterococcus K57.40 Diverticulitis, intestine, large, with small intestine, with perforation 7. A41.3 Sepsis, Haemophilus influenzae R65.21 Sepsis, severe, with septic shock N17.9 Failure, renal acute 8. A37.01 Whooping cough, due to Bordetella, pertussis, with pneumonia 9. B16,2 Hepatitis, B, acute, with, hepatic coma 10. B37.81, Esophagitis, candidal A combination code exists in ICD-10-CM to identify the myotic condition of candidiasis occurring in the esophagus and causing an esophagitis condition. 11. PROCEDURE: Insertion of multilumen central venous catheter into the right subclavian vein for intravenous infusion by percutaneous approach Character Code Explanation Section 0 Medical and Surgical Body System 5 Upper Veins Root Operation H Insertion Body Part 5 Subclavian Vein, Right Approach 3 Percutaneous Device 3 Infusion Device Qualifier Z No Qualifier INDEX: Insertion of device in, vein, subclavian, right 05H5 12. PROCEDURE: Exploratory laparotomy and small-bowel resection of 50 cm portion of the jejunum with side-to-side, functional end-to-end sewn anastomosis of the jejunum. The patient has peritonitis and a twisted nonviable small bowel. Character Code Explanation Section 0 Medical and Surgical Body System D Gastrointestinal System Root Operation B Excision Body Part A Jejunum Approach 0 Open Device Z No Device Qualifier Z No Qualifier INDEX: Excision, jejunum 0DBA. The physician states resection but according to the definition of the root operations resection and excision, this operation is an excision because only a portion of the small bowel/jejunum. The approach is open as stated by exploratory laparotomy. Anastomosis should not be assigned separately. New coding guideline in 2013. B3.1b Components of a procedure specified in the root operation definition and explanation are not coded separately. Procedural steps necessary to reach the operative site and close the operative site, including anastomosis of a tubular body part, are also not coded separately. Example: Resection of a joint as part of a joint replacement procedure is included in the root operation definition of Replacement and is not coded separately. Laparotomy performed to reach the site of an open liver biopsy is not coded separately. In a resection of sigmoid colon with anastomosis of descending colon to rectum, the anastomosis is not coded separately. 13. PROCEDURE: Insertion of venous access device/port percutaneously into the subclavian vein advanced to the superior vena cava with a pocket for the port placed in the subcutaneous tissue of the chest wall for chemotherapy to treat colon carcinoma. An incision is made to create the pocket. Character Code Explanation Section 0 Medical and Surgical Body System 2 Heart and Great Vessels Root Operation H Insertion Body Part V Superior Vena Cava Approach 3 Percutaneous Device 3 Infusion Device Qualifier Z No Qualifier INDEX: Insertion of device into vena cava, superior 02HV. The infusion device catheter is inserted into the superior vena cava by percutaneous approach with the device remaining in the vessel 13. PROCEDURE: Insertion of VAD portion of procedure described above Character Code Explanation Section 0 Medical and Surgical Body System J Subcutaneous Tissue and Fascia Root Operation H Insertion Body Part 6 Subcutaneous Tissue and Fascia, Chest Approach 0 Open Device X Vascular Access Device Qualifier Z No Qualifier INDEX: Insertion of device into subcutaneous tissue, chest 0JH6. The venous access port is placed in the subcutaneous tissue in the chest wall. This is an insertion of device left in place in the subcutaneous tissue. The coder should not use the Index entry of “insertion of device, in chest wall” because the chest wall is a different anatomic deeper location.. The approach is open because an incision is made. The device is not specified as a “reservoir” so the device “X” is chosen for the VAD. 14. PROCEDURE: Low anterior sigmoid colon (30 cm) open resection with end-to-end anastomosis of sigmoid to sigmoid colon. Character Code Explanation Section 0 Medical and Surgical Body System D Gastrointestinal System Root Operation B Excision Body Part N Sigmoid Colon Approach 0 Open Device Z No Device Qualifier Z No Qualifier INDEX: Excision, colon, sigmoid 0DBN. The procedure is an excision because only 30 cm of sigmoid colon was removed. Anastomosis should not be assigned separately. New coding guideline in 2013. This procedure is an excision with colostomy creation. Guideline B3.1b Components of a procedure specified in the root operation definition and explanation are not coded separately. Procedural steps necessary to reach the operative site and close the operative site, including anastomosis of a tubular body part, are also not coded separately. Example: Resection of a joint as part of a joint replacement procedure is included in the root operation definition of Replacement and is not coded separately. Laparotomy performed to reach the site of an open liver biopsy is not coded separately. In a resection of sigmoid colon with anastomosis of descending colon to rectum, the anastomosis is not coded separately. 15. PROCEDURE: Removal of implanted infusion port from the subcutaneous tissue in patient’s chest by incision following completion of infusion therapy Character Code Explanation Section 0 Medical and Surgical Body System J Subcutaneous Tissue and Fascia Root Operation P Removal Body Part T Subcutaneous Tissue and Fascia, Trunk Approach 0 Open Device 3 Infusion Device Qualifier Z No Qualifier INDEX: Removal of device from, subcutaneous tissue and fascia, trunk 0JPT (Chest) by incision or open approach. An implanted infusion port is an infusion device that is different from a venous access device or a reservoir Chapter 5 Neoplasms Review Exercises 1. C34.31 Carcinoma, see also Neoplasm, by site, malignant. Refer to Neoplasm Table, by site (lung), lower lobe, malignant, primary site C77.1 Refer to Neoplasm Table, by site, lymph gland, intrathoracic, malignant, , secondary site. C79.31 Refer to Neoplasm Table, by site, brain, malignant, secondary site. C79.51 Refer to Neoplasm Table, by site, bone, rib, malignant, secondary site. The primary site is the small cell carcinoma of the right lower lobe of the lung. The intrathoracic lymph nodes, brain, and rib are secondary sites. Index the term Carcinoma because the histological term is documented. This refers you to the Neoplasm Table, by site, malignant. It is correct to list each metastatic site. 2. D3A.021 Carcinoid, see Tumor, carcinoid, benign, cecum. When indexing carcinoid, the note directs to Tumor. It is not necessary to use the Neoplasm Table to code this tumor. Under carcinoid, there is a differentiation between benign or malignant, with specific sites listed. Benign carcinoid tumors fall into category D3A, Benign neuroendocrine tumors. The following notes are present: Code also any associated multiple endocrine neoplasia [MEN] syndromes; and Use additional code to identify any associate endocrine syndrome, such as: carcinoid syndrome (E34.0). 3. C93.91 Leukemia, monocytic (subacute) in remission Monocytic leukemia as stated in this exercise is not specified so an unspecified code is used. The fifth character of 1 is assigned for the status of being in remission. The term subacute is a nonessential modifier that has no influence on coding the condition. 4 C69.41 Melanoma, spindle cell, type A (right) Melanoma is not coded from the Neoplasm Table, but rather indexed under the term Melanoma. The specific type is type A spindle cell that is indexed under spindle cell. The 5th character is identified in the Tabular List for the right ciliary body of the eye 5. G89.3 Pain, chronic, neoplasm related C79.51 Carcinoma, see also Neoplasm, by site, malignant. Refer to Neoplasm Table, by site bone, vertebrae, malignant, secondary site C34.02 Refer to Neoplasm Table, by site, lung, main bronchus (left) , malignant, primary site ICD-10-CM coding guideline I.s that when the reason for the encounter is for neoplasm-related pain control or pain management, the pain code may be assigned as the first-listed diagnosis. The underlying neoplasms should be reported as additional diagnoses. 6. C78.7 Refer to Neoplasm Table, by site, liver, malignant, secondary site Z85.038 History, personal, malignant neoplasm (of), colon Z90.49 Absence (of) (organ or part) (complete or partial), intestine, large (acquired) Z92.21 History, chemotherapy for neoplastic condition Z93.3 Colostomy, status The reason for this encounter is the metastatic liver cancer. The colon cancer was previously excised with no further treatment directed at that site, therefore, it is coded as history of colon cancer. Because the patient had a previous colon excision , a code for the acquired absence of the large intestine is also coded. There is also a code available for history of chemotherapy and for the presence (status) of a colostomy. . 7. Z51.11 Chemotherapy (session) (for), cancer C25.0 Carcinoma, see also Neoplasm, by site, malignant. Refer to Neoplasm Table, by site, pancreas, head , malignant, primary site Z90.411 Absence, pancreas, acquired, partial The reason for the encounter (chemotherapy) is the first listed diagnosis. Coding guidelines 1.C.2.e.2 describes the coding of encounters solely for administration of chemotherapy. The neoplasm is coded as current (even though it was excised) because the patient is still receiving chemotherapy. The acquired absence of the pancreas may be coded. 8. Z51.0 Admission for, radiation therapy (antineoplastic) C61 Carcinoma, see also Neoplasm, by site, malignant. Refer to Neoplasm Table, by site, prostate , malignant, primary site The reason for the encounter (radiation therapy) is the first listed diagnosis. The neoplasm is coded as current as the tumor has not been excised and the patient is receiving radiation therapy. Coding guideline I.C.2.e.2 describes the coding of encounters solely for administration of radiation therapy 9. C78.01 Metastatic, cancer, to specific site —see Neoplasm, secondary by site Neoplasm, lung, (right) , malignant secondary Z85.528 History, personal, malignant neoplasm, kidney Z92.21 History, personal, chemotherapy for neoplastic condition Z92.3 History, personal, radiation therapy The reason for the visit is evaluation of the metastatic carcinoma of the lung which is the first-listed code. History of kidney cancer which was the primary site was coded as a secondary diagnosis. Also coded was the patient’s history of receiving chemotherapy and radiation therapy 10. C7A.022 Tumor, carcinoid, malignant, ascending colon E34.0 Syndrome, carcinoid The patient was seen during this visit for the malignant carcinoid tumor in the ascending colon. In addition the patient was treated for the carcinoid syndrome that is a result of the carcinoid tumor. A “use additional code” note to identify any associated endocrine syndrome, such as: carcinoid syndrome (E34.0) appears under category C7A, Malignant neuroendocrine tumors. 11. PROCEDURE: Ultrasound probe-guided prostate needle biopsy via rectum. One needle core biopsy submitted for diagnostic evaluation. Character Code Explanation Section 0 Medical and Surgical Body System V Male Reproductive System Root Operation B Excision Body Part 0 Prostate Approach 7 Via Natural or Artificial Opening Device Z No Device Qualifier X Diagnostic INDEX: Biopsy see Excision with qualifier diagnostic. Excision, prostate 0VB0. The needle biopsy is done to obtain tissue for pathological examination for a definitive diagnosis. If multiple prostate biopsies were performed, the code 0VB07ZX would be assigned for each biopsy taken according to ICD-10-PCS guideline B3.2b to code multiple procedures when the same root operation is repeated at different body sites that are included in the same body part value (prostate.) The approach performed through the rectum is assigned the approach of “via natural or artificial opening.” PROCEDURE: Ultrasound portion of procedure described above Character Code Explanation Section B Imaging Body System V Male Reproductive System Root Type 4 Excision Body Part 9 Prostate and seminal vesicles Contrast Z Via Natural or Artificial Opening Device Z None Qualifier Z None INDEX: Ultrasonography, prostate and seminal vesicles BV49ZZZ 12. PROCEDURE: Right breast lumpectomy with sentinel lymph node biopsy, right axilla Character Code Explanation Section 0 Medical and Surgical Body System H Skin and Breast Root Operation B Excision Body Part T Breast, Right Approach 0 Open Device Z No Device Qualifier Z No Qualifier INDEX: Lumpectomy see Excision, breast, right 0HBT. Lumpectomy is an open procedure The lumpectomy is a therapeutic procedure to remove a tumor within the breast. PROCEDURE: Sentinel node biopsy, right axilla Character Code Explanation Section 0 Medical and Surgical Body System 7 Lymphatic and Hemic Systems Root Operation B Excision Body Part 5 Lymphatic, Right Axillary Approach 0 Open Device Z No Device Qualifier X Diagnostic INDEX: Biopsy, see Excision, lymphatic, axillary, right 07B5. Sentinel node biopsies are open procedures. The qualifier X is used to identify the excision as a biopsy. A sentinel node biopsy is done to obtain tissue for pathological examination to determine if disease is present. 13. PROCEDURE: Open resection and removal of the left lobe of the liver due to metastasis from colon carcinoma Character Code Explanation Section 0 Medical and Surgical Body System F Hepatobiliary System and Pancreas Root Operation T Resection Body Part 2 Liver, Left Lobe Approach 0 Open Device Z No Device Qualifier Z No Qualifier INDEX: Resection, liver, left lobe 0FT2 This procedure is a resection by definition because the entire body part, left lobe of liver, was removed 14. PROCEDURE: Tube Thoracostomy—chest tube insertion by incision—for drainage of malignant pleural effusion from right side of pleural cavity Character Code Explanation Section 0 Medical and Surgical Body System W Anatomical Regions, General Root Operation 9 Drainage Body Part 9 Pleural Cavity, Right Approach 0 Open Device 0 Drainage Device Qualifier Z No Qualifier INDEX: Thoracostomy tube see Drainage Device, pleural cavity 0W99. The objective of this procedure is to drain fluid to remove the effusion through a drainage device, in this case, the chest tube. 15. PROCEDURE: Rigid Bronchoscopy with YAG laser photoresection for the destruction of lesion in the right main bronchus Character Code Explanation Section 0 Medical and Surgical Body System B Respiratory System Root Operation 5 Destruction Body Part 3 Main Bronchus, Right Approach 8 Via Natural or Artificial Opening Endoscopic Device Z No Device Qualifier Z No Qualifier INDEX: Destruction, bronchus, main, right 0B53. Laser photoresection is a destruction procedure. Approach is endoscopy by bronchoscopy. A bronchoscopy is involves visualization of the respiratory system by entering through the pharynx or nasopharynx which is a natural opening using an endoscopic device. Chapter 6 Diseases of the Blood and Blood- Forming Organs and Certain Disorders Involving the Immune Mechanism Review Exercises: Chapter 6 1. D50.0 Anemia, iron deficiency, secondary to blood loss (chronic). This condition may also be referred to posthemorrhagic anemia (chronic.) 2. D68.0, Von Willebrand's disease or syndrome. Disease, von Willebrand 3. D73.2 Splenomegaly, congestive, chronic 4. D55.8, Anemia, hemolytic, nonspherocytic, congenital The important term is here nonspherocytic. A different disease is spherocytic anemia that is included in the Index as anemia, spherocytic—Spherocytosis, D58.0 5. D69.3, Purpura, thrombocytopenia, idiopathic This condition may be documented as immune thrombocytopenic purpura or hemorrhagic purpura 6. D61.09, Anemia, Fanconi's This condition may also be referred to as constitutional aplastic anema 7. D65, Coagulation, intravascular—See also Defibrination syndrome This condition may commonly be documented as diffuse or disseminated intravascular coagulation abbreviated as DIC. 8. D62, Anemia, blood loss, acute 9. D56.1, Anemia, Cooley's This condition may also be documented as beta thalassemia major or thalassemia major 10. D75.1, Polycythemia due to high altitude 11. D55.0, Anemia, glucose-6-phosphate dehydrogenate 12. . D75.82, Thrombocytopenia, heparin induced (HIT) 13. D57.419 Thalassemia, sickle-cell—see Disease, sickle-cell, thalassemia, with crisis 14. N18.6 Disease, end stage renal D63.1 Anemia, due to (in) (with) chronic kidney disease Code first underlying chronic kidney disease (CKD) (N18.-) 15. D70.9, Neutropenic fever Use additional code for any associated fever (R50.81) R50.81, Fever presenting with conditions classified elsewhere 16. PROCEDURE: Transfusion via peripheral vein, Blood Platelets, Nonautologous donor blood Character Code Explanation Section 3 Administration Physiological System 0 Circulatory Root Operation 2 Transfusion Body System/Region 3 Peripheral Approach 3 Percutaneous Substance R Platelets Qualifier 1 Nonautologous INDEX: Transfusion, Vein, Peripheral, Blood, Platelets, 3023 A transfusion is completed by a percutaneous puncture into a peripheral vein for infusion. 17. PROCEDURE: Therapeutic Plasmapheresis, Single Session Character Code Explanation Section 6 Extracorporeal Therapies Body System A Physiological Systems Root Operation 5 Pheresis Body System 5 Circulatory Duration 0 Single Qualifier Z No Qualifier Qualifier 3 Plasma INDEX: Plasmapheresis, 6A550Z3. The coder must be careful not to confuse the main term plateletpheresis, therapeutic with plasmapheresis. It is important to validate the code obtained in the Index in the code table as done here. The qualifier distinguishes between substances that can be infused. 18. PROCEDURE: Bone Marrow Needle Extraction Biopsy, Iliac Character Code Explanation Section 0 Medical and Surgical Body System 7 Lymphatic and Hemi Systems Root Operation D Extraction Body Part R Bone Marrow, Iliac Approach 3 Percutaneous Device Z No Device Qualifier X Diagnostic INDEX: Extraction, Bone Marrow, Iliac, 07DR Bone marrow biopsies are not coded to excisions as there is no cutting but instead involve pulling out tissue from the bone. Therefore, bone marrow biopsies or aspirations are extractions with qualifier of X as these are diagnostic procedures. 19. PROCEDURE: Laparoscopic total splenectomy Character Code Explanation Section 0 Medical and Surgical Body System 7 Lymphatic and Hemic Systems Root Operation T Resection Body Part P Spleen Approach 4 Percutaneous Endoscopic Device Z No Device Qualifier Z No Qualifier INDEX: Splenectomy, see Excision or Resection, Lymphatic and Hemic Systems, total splenectomy would be Resection, 07T. A laparoscopic approach is a percutaneous endoscopy as the trocars and ports used in a laparoscopic are placed in the body percutaneously so that the device of the laparoscope can be inserted. 20. PROCEDURE: Lymph Node Open Biopsy by Excision, Right Axilla Character Code Explanation Section 0 Medical and Surgical Body System 7 Lymphatic and Hemic Systems Root Operation B Excision Body Part 5 Lymphatic, Right Axillary Approach 0 Open Device Z No Device Qualifier X Diagnostic INDEX: Biopsy see Excision with Qualifier, Excision, Lymphatic, Axillary, Right 07B5 Chapter 7 Endocrine, Nutritional, and Metabolic Diseases Review Exercise: Chapter 7 1. Type 2 diabetic with nephropathy due to the diabetes E11.21 Diabetes, type 2, with, nephropathy 2. Toxic diffuse goiter with thyrotoxic storm E05.01 Goiter, toxic—see Hyperthyroidism, with goiter (diffuse), with thyroid storm 3. Cushing’s syndrome E24.9 Syndrome, Cushing's 4. Hypokalemia E87.6 Hypokalemia 5. Cystic fibrosis with pulmonary manifestations E84.0 Fibrosis, cystic, with, pulmonary manifestations 6. Uncontrolled (hyperglycemia) type 2 diabetes mellitus; mild degree malnutrition E11.65 Diabetes, type 2, with, hyperglycemia E44.1 Malnutrition, degree, mild There is no combination code for diabetes and malnutrition, nor is there a stated cause-and-effect relationship between diabetes and malnutrition There are no ICD-10-CM codes that state “uncontrolled” diabetes but instead the uncontrolled status is identified as diabetes with hyperglycemia. Uncontrolled diabetes means the patient has elevated glucose levels. In this example, there is no stated relationship between the diabetes and the malnutrition so the condition is coded separately. 7. Panhypopituitarism E23.0 Panhypopituitarism 8. Lower extremity ulcer on skin of left heel secondary to brittle diabetes mellitus, type 1, uncontrolled E10.621 Diabetes, type 1, with foot ulcer L97.429 Ulcer, heel - see Ulcer, lower limb, heel, left E10.65 Diabetes, type 1, with, hyperglycemia (uncontrolled) 9. Diabetic proliferative retinopathy in a patient with controlled type 1 diabetes E10.359 Diabetes, with, retinopathy, proliferative 10. Overweight adult with a body mass index (BMI) of 26.5 E66.3 Overweight Z68.26 Body, mass index, adult, 26.0- 26.9 11. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) E22.2 Syndrome, inappropriate secretion of antidiuretic hormone 12. Hypoglycemia in type 1 diabetes with coma E10.641 Diabetes, type 1, with, hypoglycemia, with coma 13. Postsurgical hypothyroidism E89.0 Hypothyroidism, postsurgical 14. Folic acid deficiency E53.8 Deficiency, folic acid 15. Partial androgen insensitivity syndrome E34.52 Syndrome, androgen insensitivity, partial 16. PROCEDURE: Open total thyroidectomy Character Code Explanation Section 0 Medical and Surgical Body System G Endocrine System Root Operation T Resection Body Part K Thyroid Gland Approach 0 Open Device Z No Device Qualifier Z No Qualifier INDEX: Thyroidectomy, see Resection, Endocrine System, thyroid gland, 0GTK. Total thyroidectomy is removal of entire thyroid. 17. PROCEDURE: Partial left lobectomy, thyroid gland, open Character Code Explanation Section 0 Medical and Surgical Body System G Endocrine System Root Operation B Excision Body Part G Thyroid Gland Lobe, Left Approach 0 Open Device Z No Device Qualifier Z No Qualifier INDEX: Lobectomy, excision, endocrine system 0GB. A thyroid lobe is a body part, so a partial excision of a body part is an excision 18. PROCEDURE: Right carotid body biopsy, open, by excision Character Code Explanation Section 0 Medical and Surgical Body System G Endocrine System Root Operation B Excision Body Part 7 Carotid Body, Right Approach 0 Open Device Z No Device Qualifier X Diagnostic INDEX: Biopsy, see Excision with qualifier diagnostic, carotid body, right, 0GB7 19. PROCEDURE: Laparoscopic partial left adrenalectomy Character Code Explanation Section 0 Medical and Surgical Body System G Endocrine System Root Operation B Excision Body Part 2 Adrenal Gland, Left Approach 4 Percutaneous Endoscopic Device Z No Device Qualifier Z No Device INDEX: Adrenalectomy, see Excision, Endocrine System, see Gland, Adrenal, left, 0G32. A partial adrenalectomy would be an excision as the total gland is not removed. The laparoscopic approach is performed through the skin with the introduction of trocars and ports percutaneously to allow the laparoscopy or endoscopic procedure to be performed. 20. PROCEDURE: Stereotactic gamma beam radiosurgery, parathyroid gland tumor Character Code Explanation Section D Radiation Oncology Body System G Endocrine System Root Type 2 Stereotactic Radiosurgery Treatment Site 4 Parathyroid Glands Modality Qualifier J Stereotactic Gamma Beam Radiosurgery Isotope Z None Qualifier Z None INDEX: Stereotactic Radiosurgery, Gamma Beam, Gland, Parathyroid, DG24JZZ Stereotactic radiosurgery is a destruction procedure of the parathyroid gland tumor using gamma beams. Chapter 8 Mental, Behavioral and Neurodevelopmental Disorders Review Exercises: Chapter 8 1. F12.280 Addiction, drug—see Dependence, drug, cannabis, with anxiety disorder 2. F20.5 Schizophrenia, chronic undifferentiated or Schizophrenia, undifferentiated, chronic (Rationale: the Index must be trusted in this example. The title and inclusion terms for ICD-10-CM code F20.5 is residual schizophrenia and does not include the terminology included in the diagnosis provided. But the Index clearly sends the coder to code F20.5 which is the correct code.) 3. F33.1 Depression, seasonal—see Disorder, depressive, recurrent, current episode, moderate (Rationale: Another example of the coder trusting the Index. The Index clearly refers the coder from the entry of depression, seasonal to disorder, depressive, recurrent as this is the nature of seasonal depression. The Index entry of disorder, depressive, recurrent directs the coder for the correct code. The category F33 includes the inclusion term of recurrent episodes of seasonal depressive disorder under the category heading) 4. F10.121 Alcoholic, intoxication (acute), with delirium Y90.7 Index to External Causes, Blood alcohol level, 200 to 239 mg/100ml (Rationale: Category F10, Alcohol related disorders, has the “use additional code note” to use a code for the blood alcohol level, if applicable. The coder must access the ICD- 10-CM Index to External Causes because a blood alcohol level is an external cause of a condition and not itself a disease. The main term is “blood alcohol level” with subterms for the various measurements of the blood alcohol level in the patient. 5. F43.12 Disorder, post-traumatic stress, chronic 6. F55.3 Abuse, steroids 7. F50.01 Anorexia, nervosa, restricting type 8. F31.62 Disorder, bipolar, current episode, mixed, moderate 9. F41.8 Anxiety depression 10. F91.3 Disorder, conduct, oppositional defiance 11. F90.1 Disorder, attention-deficit hyperactivity (adult), hyperactive type 12. I67.2 Arteriosclerosis, cerebral F01.50 Dementia, arteriosclerotic—see Dementia, vascular, Code first note under category F01, Vascular dementia—Code first underlying physiological condition or sequelae of cerebrovascular disease. 13. F53Depression, postpartum 14. F80.81 Stuttering, childhood onset 15. F80.1 Dysphasia, developmental, expressive F71 Disabilities, intellectual, moderate Under section F70–F79, Intellectual Disabilities, is a note to code first any associated physical or development disorders 16. F68.12 Munchhausen’s syndrome—see Disorder, factitious, with predominantly physical symptoms 17. F11.23 Addiction, heroin—see Dependence, drug, opioid, with, withdrawal 18. F60.3 Disorder, personality, explosive 19. F17.210 Smoker—see Dependence, drug, nicotine, cigarettes 20. F14.182 Hypersomnia, due to, cocaine, abuse Another entry in the Index that can be uses is “Abuse, cocaine, with sleep disorder.” 21. PROCEDURE: Individual cognitive psychotherapy for mental health treatment Character Code Explanation Section G Mental Health Section Body System Z None Root Type 5 Individual Psychotherapy Type Qualifier 2 Cognitive Qualifier Z None Qualifier Z None Qualifier Z None INDEX: Psychotherapy, individual, mental health, cognitive, GZ52ZZZ 22. PROCEDURE: Electroconvulsive therapy, bilateral, single seizure Character Code Explanation Section G Mental Health Section Body System Z None Root Type B Electroconvulsive Therapy Type Qualifier 2 Bilateral-single seizure Qualifier Z None Qualifier Z None Qualifier Z None INDEX: Electroconvulsive therapy, bilateral single seizure, GZB2ZZZ 23. PROCEDURE: Intellectual and psychoeducational psychological test Character Code Explanation Section G Mental Health Section Body System Z None Root Type 1 Psychological Tests Type Qualifier 2 Intellectual and psychoeducational Qualifier Z None Qualifier Z None Qualifier Z None INDEX: Psychological tests, intellectual and psychoeducational, GZ12ZZZ 24. PROCEDURE: Cognitive-behavioral group counseling for substance abuse treatment Character Code Explanation Section H Substance Abuse Treatment Body System Z None Root Type 4 Group counseling Type Qualifier 2 Cognitive-behavioral Qualifier Z None Qualifier Z None Qualifier Z None INDEX: Counseling, group, cognitive-behavioral HZ42ZZZ 25. PROCEDURE: Drug detoxification treatment for substance abuse Character Code Explanation Section H Substance Abuse Treatment Body System Z None Root Type 2 Detoxification services Type Qualifier Z None Qualifier Z None Qualifier Z None Qualifier Z None INDEX: Detoxification services, for substance abuse HZ2ZZZZ Chapter 9 Diseases of the Nervous System Review Exercises: Chapter 9 1. G30.0 Alzheimer’s disease or sclerosis, see Disease, Alzheimer’s, early onset, with behavioral disturbance F02.81 Dementia, in Alzheimer’s disease, see Disease, Alzheimer’s There is mandatory sequencing for these codes. The etiology (Alzheimer’s disease) is sequenced first and the manifestation (dementia) is sequenced second. The Index provides the following documentation: Alzheimer’s, early onset, without behavioral disturbance G30.0 [F02.81]. The use of the brackets in the Index indicates manifestation codes. Further the note in the Tabular at the G30 category states to use an additional code to identify dementia without behavioral disturbance (F02.81) At the F02 category, the note states to code first the underlying physiological condition. 2. G40.319 Epilepsy, juvenile myoclonic— see epilepsy, generalized, idiopathic. Epilepsy, generalized, idiopathic, intractable, without status epilepticus 3. Episodic cluster headache, not described as intractable G44.019, Headache, cluster, episodic, not intractable The Index entry is straightforward. The G44.019 is the default code for an episodic cluster headache that has no documentation of whether the headache is intractable or not. This would be a reasonable query for the physician as It would contribute to the best coding for the condition. 4. Chronic Migraine without aura, not intractable with status migrainous G43.701 Migraine, chronic, not intractable, with status migrainous The Index entries for migraine must be followed closely for such entries as "with" and "without" aura, persistent or chronic, intractable or not intractable, with or without status migrainous. 5. Autonomic dysreflexia due to urinary tract infections G90.4 Dysreflexia, autonomic N39.0 Infection, urinary (tract) A "use additional code" note appears under code G90.4 to use an additional code for the cause, as In this case the urinary tract Infection. There is also a note under code N39.0 to use additional code (B95–B97) to identify infectious agent. In this example, there is no mention of the infectious agent so no code is applied. 6. Idiopathic normal pressure hydrocephalus G91.2 Hydrocephalus, normal pressure. There is no Index entry for idiopathic under hydrocephalus but when the Tabular List is referenced, the title of code G91.2 includes (Idiopathic) normal pressure hydrocephalus so the term idiopathic in parentheses means the presence or absence of the term does not impact the code assignment. 7. G45.9 Attack, attacks, transient ischemic (TIA) E11.40 Diabetes, diabetic, (mellitus) (sugar) type 2, with, neuropathy G43.119 Migraine, classical—see Migraine, with aura Migraine, with aura, intractable The TIA is the first listed diagnoses as it was the reason for the encounter. The migraine is documented as classical. In ICD-10-CM, classical migraine is classified to with aura. 8. G70.01 Myasthenia., gravis, in crisis The Index entries for myasthenia is straightforward. Another description of myasthenia gravis that could code to G70.01 would be myasthenia gravis with acute exacerbation or simply with exacerbation 9. G31.2 Encephalopathy, alcoholic F10.20 Alcoholism “Code also associate alcoholism (F10.-)” appears under code G31.2. This direction is not provided in the Index and demonstrates the requirement to review the Tabular List for complete coding instructions. 10. G90.523 Syndrome, pain, complex regional I, lower limb G90.52-Index entries include syndrome, complex regional pain—see Syndrome, pain, complex regional with additional subterms for lower limb, specified site NEC and upper limb. 11. Intracranial subdural abscess due to methicillin resistant Staphylococcus aureus G06.0 Abscess, intracranial or Abscess, subdural, brain. There is a use additional code (B95–B97) to identify the infectious organism. B95.62 Infection, staphylococcal, as cause of disease classified elsewhere, aureus, methicillin resistant 12. Carpal tunnel syndrome and tarsal tunnel syndrome, both on left side G56.02 Syndrome, carpal tunnel, left upper limb G57.52 Syndrome, tarsal tunnel, left lower limb The Index entries are straightforward. No site is included in the Index, such as upper limb or lower limb. The Index can be trusted as carpal tunnel syndrome only occurs in the upper limb and tarsal tunnel syndrome only occurs in the lower limb. 13. Spastic diplegic cerebral palsy G80.1 Palsy, cerebral, spastic, diplegic The Index entries for spastic cerebral palsy and spastic diplegic cerebral palsy both code to G80.1 14. Dementia with Parkinsonism G31.83 Dementia, with Parkinsonism G31.83, [F02.80] F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance The Index must be followed closely for this condition. Under main term Dementia, the coder must note the connecting term “with” directly under the main term and two entries exist that produce different codes: Parkinson’s Disease G20 and Parkinsonism G31.83. Another potential error would be if the coder accessed the main term Dementia “in” Parkinson’s Disease G20, [F02.80]. If the coder accessed “Parkinsonism” code G20 would be found. When the coder accessed the Tabular List with G20, an important Excludes1 note is found: Dementia with Parkinsonism (G31.83). In this example, the coder cannot exchange the term Parkinson’s Disease with Parkinsonism. 15. Postpolio Syndrome G14 Syndrome, postpolio (myelitic) The Index entry is straightforward to code G14. In the Tabular List, there is an Excludes1 note under code G14 that excludes code G14 being used with sequelae of poliomyelitis. Postpolio syndrome is a current condition in a patient who had poliomyelitis in the past but after a stable period of time, the patient develops new muscle weakness, muscle atrophy and possibly fatigue and muscle pain. This code is not used to identify polio as the late effect of a current residual condition as is the intent of code B91. 16. PROCEDURE: Diagnostic lumbar spinal puncture Character Code Explanation Section 0 Medical and Surgic