Mastery: Real-World Procedure Coding & Expert
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Alteration - answer Modification of a natural anatomic structure
of a boy part without affecting the function of the body part...
Character: 0 (zero).
Alteration is a procedure most often performed for cosmetic
purposes, to improve the patient's appearance, such as a face lift.
Example: 0J013ZZ Alteration of subcutaneous tissue and fascia,
face, percutaneous approach.
Bypass - answer Altering the route of the contents of a tubular
body part.. Character 1.
Bypass procedures are coded by identifying the body part
bypassed "from," identified by character 4 (Body part), and the
body part bypassed "to," identified by character 7 (Qualifier).
A bypass can be performed only on a tubular body part, such as a
vein or an artery, the esophagus, or the intestines. A colostomy
formation is another example of a bypass.
Example: 02114Z8 Coronary artery bypass, one site,
percutaneous endoscopic approach, rerouted to internal
mammary, right side.
, Change - answer Taking out or off a device from a body part and
putting back an identical or similar device in or on the same body
part without cutting or puncturing the skin or a mucous
membrane. Character 2.
Change is a root operation only used when a device is involved in
the procedure- a device that stays with the patient after the
procedure is complete. A urinary catheter change or gastronomy
tube change are good examples. Often, this term will actually be
used in the documentation.
Example: 0020X0Z Changing a drainage device in the brain,
external approach.
Control - answer Stopping, or attempting to stop, post
procedural or other acute bleeding. Character 3.
This root operation term is used only when the only action taken
during this procedure is the intent to stop the hemorrhage. If
Control is unsuccessful and another procedure was performed to
accomplish the task, then report the code for that root operation
instead of control, such as excision. You would not use both.
Example: 0W3B0ZZ Control post-procedural bleeding in the
pleural cavity, left side, open approach.
Creation - answer Putting in or on biological or synthetic material
to form a new body part that to the extent possible, replicates the
anatomic structure or function of an absent body part. Character
4.