question

Biliary system

answer

...network including the gallbladder and bile ducts

question

Calculus

answer

Histone composed of minerals that forms in an organ or duct of the body

question

Diverticulitis

answer

Inflammation of existing diverticula

question

Diverticulosis

answer

The presence of one or more diverticula of the designated site

question

Diverticulum

answer

A small pouch or Sac opening from a tubular or saccular organ - considered a medical condition - can be acquired or congenital

question

Esophagitis

answer

K20 An inflammation of the lining of the esophagus K2 0.0, eosinophilic esophagitis K2 0.8 , other esophagitis K2 0.9, unspecified esophagitis K2 1.0, esophagitis with gastroesophageal reflux disease

question

Esophageal varices

answer

I85.00, esophageal varices without bleeding I85.01, esophageal varices with bleeding Definition: Abnormally enlarged veins in the lower part of the esophagus

question

GI

answer

Gastrointestinal - of the stomach and / or intestines

question

Hematemesis

answer

K9 2.0 Vomiting of blood - which indicates acute upper gastrointestinal hemorrhage

question

Melena

answer

K 92.1 Presence of dark colored blood in stool - which indicates upper or lower GI hemorrhage

question

Occult bleeding

answer

Presence of blood in stool that can only be seen on laboratory examination - indicates upper or lower GI bleeding

question

Hematochezia

answer

Presence of bright colored blood in stool - which indicates lower GI bleeding

question

The most common causes of GI bleeding

answer

Gastric and intestinal ulcers and diverticular disease of the intestines - diverticular hemorrhage stop spontaneously in approximately 80% of cases - the other 20% experiencing a second or third bleeding episode

question

Acute gastritis with hemorrhage

answer

K2 9.01

question

Diverticulitis of small intestine with hemorrhage

answer

K5 7.13

question

Angiodysplasia of duodenum with hemorrhage

answer

K3 1.811

question

Gastrointestinal Hemorrhage unspecified

answer

K9 2.2

question

Coding / GI hemorrhage - combo codes

answer

Combination codes describing Hemorrhage should not be assigned unless the physician identifies a causal relationship

question

Hemorrhage of anus and rectum

answer

K-6 2.5 The findings include internal and external hemorrhoids with no statement as to whether the rectal bleeding is due to the hemorrhoids - physician should be queried to determine whether the rectal bleeding is secondary to the hemorrhoids or the hemorrhoids are an incidental finding

question

Hemorrhoids, other

answer

K-6 4.8, other hemorrhoids And K-6 4.4, residual hemorrhoidal skin tags The Physician establishes a causal relationship between the bleeding and the hemorrhoids

question

Esophagitis with other diseases of the esophagus

answer

K22 K2 2.10 , ulcer of esophagus without bleeding K2 2.11, ulcer of esophagus with bleeding K2 2.4, dyskinesia of esophagus K2 2.4 , spasm of esophagus K2 2.70 - K22.71 - , Barrett's esophagus

question

Definition / Barrett's esophagus

answer

Precancerous condition in which the normal cells of the lining of the esophagus are replaced by columnar cells

question

Bleeding of the esophagus

answer

K2 2.8, other specified diseases of the esophagus

question

Coding / esophageal varices

answer

When associated with alcoholic liver disease, cirrhosis of the liver, schistosomiasis, toxic liver disease, or portal hypertension - dual coding is required: Code 1st - underlying condition Code 2nd - esophageal varices *I85.10 - I85.11* K7 4.60 + I85.11 comma bleeding esophageal varices with cirrhosis of liver K7 6.6 + I85.11 , bleeding esophageal varices and portal hypertension

question

PCS coding / Esophageal varices - occlusion

answer

Root operation - occlusion 06L30ZZ, occlusion of esophageal vein open approach 06L33ZZ, occlusion of esophageal vein percutaneous approach 06L33ZZ, occlusion of esophageal vein percutaneous endoscopic approach 06L34CZ, occlusion of esophageal vein with extraluminal device, percutaneous endoscopic approach

question

PCS coding / Esophageal varices - introduction

answer

3E0G8TZ, introduction of destructive agent into upper GI, via natural or artificial opening endoscopic

question

Coding / Combo codes - Ulcers of the stomach and small intestine

answer

Combination codes are provided for gastric, gastrojejunal, and duodenal ulcers that indicate whether there is associated bleeding, associated perforation, or both - codes also distinguish between acute and chronic ulcers

question

Peptic ulcer

answer

K-27, peptic ulcer, site unspecified Note - should not be used when a more specific code can be assigned ...coder should review the medical record for any indication of the site involved K2 5.5, chronic gastric ulcer with perforation K2 6.3, acute duodenal ulcer K2 5.6, gastric ulcer with Hemorrhage and perforation

question

dieulafoy lesions

answer

K31.82, dieulafoy lesions of the stomach and duodenum K63.81, dieulafoy lesions of the intestine K22.8, dieulafoy lesions of the esophagus Rare cause of major gastrointestinal bleeding Dash when present a separate code for the GI bleeding is not assigned because it is an intrical part of the disease

question

Complications of artificial openings of the digestive system

answer

K94, complications of colostomy, enterostomy, gastrostomy, esophagostomy

question

Complications of colostomy and enterostomy

answer

K9 4.01, colostomy hemorrhage K9 4.03, malfunction of colostomy K9 4.12 + L03.311, cellulitis of abdominal wall due to complications of enterostomy

question

Complications of gastrostomy and esophagostomy

answer

K94.32, infection of the esophagostomy Add code - specify the infection K94.33, malfunction of the esophagostomy K94.23, mechanical complication of gastrostomy K94.22, infection of gastrostomy Add code - specify type of infection

question

CM Coding - *RULE*: diverticulosis/diverticulitis

answer

Diverticulosis indicates the presence of one or more diverticula of the designated site - diverticulitis is the inflammation of existing diverticula. A diagnosis of diverticulitis assumes the presence of diverticula/diverticulosis; code only for diverticulitis if both are diagnosed.

question

Coding / Diverticulosis and diverticulitis

answer

K5 7.10, diverticulosis of duodenum K5 7.12, diverticulosis and diverticulitis of duodenum K5 7.13, diverticulitis of jejunum with hemorrhage K5 7.20, diverticulitis of cecem with abscess

question

Coding / Diverticulum

answer

K2 2.5, diverticulum of esophagus, acquired K2 2.5 , epiphrenic diverticula of esophagus K22.5, midesophageal traction diverticula of esophagus

question

PCS coding / GI system

answer

For root operations Change, inspection, removal, revision Upper intestinal tract GI tract from esophagus down to and including the duodenum Lower intestinal tract Portion of the GI tract from the jejunum down to and including the rectum and anus

question

PCS coding / Reach & close

answer

Procedural steps necessary to reach the operative site and close the operative site are not coded separately

question

Cholecystitis without associated calculus

answer

K81 Add characters - whether: K8 1.0, acute K8 1.1, chronic K8 1.2, acute and chronic K8 1.9, unspecified

question

Coding / biliary system - combo codes

answer

Combo codes are assigned for cholecystitis, cholelithiasis, choledocholithiasis to permit reporting these related conditions with a single code. K8 0.0 - through k-8 0.2 -, calculus of gallbladder K8 0.3 - 3K a 0.5 -, calculus of bile duct K8 0.6 - K80.7 -, calculus of both gallbladder and bile ducts Within K-8 0.0 -, K8 0.1 -, K8 0.2 -, K8 0.4 -, Ka 0.6 - , K8 0.7 - , Fourth character - indicates whether there is cholangitis rather than cholecystitis K8 0.3, Fourth character - indicates there is neither: cholangitis nor cholecystitis K8 0.66, k80 .67 , combo codes - include calculus of gallbladder and bile duct with both acute and chronic cholecystitis 5th character in category K80 - cholelithiasis, indicates whether there is an associated obstruction

question

Coding / Biliary system - obstruction

answer

K82.0, obstruction of gallbladder And K83.1, obstruction of bile duct ...assigned only when there is obstruction but no calculi are present

question

Cholesterolosis / strawberry gallbladder

answer

A condition characterized by abnormal deposits of cholesterol and other lipids in the lining of the gallbladder - in its diffuse form it is known as strawberry gallbladder - not to be coded when other gallbladder pathology is present

question

Postcholecystectomy syndrome

answer

K9 1.5, A condition in which symptoms suggestive of biliary tract disease either persist or develop following cholecystectomy with no demonstrable cause or abnormality found on workup Note - postoperative complication code from 280 - 288 is not assigned with this code

question

Cholecystectomy

answer

Root operation: resection (total) OR excision (partial) Note - coder should review the op report to determine whether exploration or incision of the bile duct was also performed for removal of stones or for other relief of obstruction as well as whether an inoperative cholangiogram was performed

question

PCS Coding / Biliary calculi

answer

Root operation - *fragmentation* 0FF6XZZ, fragmentation in left hepatic duct, external approach ...if lithotripsy involves removal of fragments, the procedure is classified to the root operation - *extirpation* instead

question

Extracorporeal shock wave lithotripsy [ESWL]

answer

Destroys biliary stones without invasive surgery - classified to the root operation *fragmentation*

question

Endoscopic retrograde cholangiopancreatography [ERCP]

answer

Procedure performed with ESWL

question

Endoscopic pancreatic sphincterotomy

answer

Procedure performed with ESWL

question

Intestinal and peritoneal adhesions

answer

K66 .0, peritoneal adhesions (post-procedural) (post infection) K5 6.5, intestinal adhesions (bands) with obstruction (post-procedural) (post infection) N7 3.6, female pelvic peritoneal adhesions (post infective)

question

PCS coding / lysis of adhesions

answer

Root operation - release 0DN80ZZ, open lysis of small intestine adhesions 0UN74ZZ, laparoscopic bilateral lysis of fallopian tube adhesions

question

Hernias of the abdominal cavity

answer

K40.00, bilateral inguinal hernia with obstruction, no mention of gangrene K40.41, unilateral recurrent inguinal hernia with gangrene K41.11, gangrenous femoral hernia, recurrent, bilateral K43.1, Recurrent ventral incisional hernia with obstruction and gangrene K44.1, diaphragmatic hernia with gangrene K42.0, umbilical hernia with obstruction K41.30, incarcerated femoral hernia ... hernias are classified by type and site - with combo codes used to indicate any associated gangrene or obstruction

question

PCS coding / herniorrhaphies

answer

Root operation - repair ...unless repair is accomplished with the use of a biological or synthetic material in which case; Root operation - supplement 0YQA0ZZ, open repair of bilateral inguinal hernia 0WQF0ZZ, open repair of ventral hernia 0YQ50ZZ, open repair of right inguinal hernia 0YU54JZ, laparoscopic repair of right inguinal hernia with mesh prosthesis 0YQA3ZZ, percutaneous repair of bilateral inguinal hernias

question

Appendicitis

answer

K35, acute appendicitis 4th char - indicates the presence of either: generalized peritonitis K3 5.2 or localized peritonitis K3 5.3 K3 5.80, unspecified acute appendicitis Note - occasionally, and appendix ruptures during an appendectomy - this is not classified as a complication of surgery. K37, unspecified appendicitis ...a vague category that should not be used in an acute care facility

question

PCS coding / Appendectomy

answer

Root operation - resection Note - PCS does not distinguish between an incidental appendectomy and an appendectomy to remove a diseased appendix Note - incidental appendectomy refers to a procedure performed to remove the appendix as a routine prophylactic measure in the course of other abdominal surgery

question

Diarrhea

answer

A00 - A09, assigned for infectious diarrhea when the organism has been identified A09, infectious diarrhea, NOS ~ dysenteric diarrhea ~ endemic diarrhea ~ epidemic diarrhea R19.7, symptom code for diarrhea for which no appropriate subterm can be located A04.7, diarrhea due to clostridium diffícile R19.7, acute diarrhea A07.3, coccidial diarrhea K52.9, chronic diarrhea R19.7, infantile diarrhea K59.1, functional diarrhea

question

Constipation

answer

K5 9.00, unspecified constipation K5 9.01, slow transit constipation K5 9.02, outlet dysfunction constipation

question

PCS coding / Bariatric surgery

answer

0DV64CZ, laparoscopic gastric restrictive procedure 0DW64CZ, laparoscopic revision of gastric band 0D160ZB, open gastric bypass stomach to ileum 0DB64Z3, laparoscopic vertical sleeve gastrectomy

question

PCS coding / Bariatric surgery complications

answer

K95, complications of bariatric procedures K95.01, infection due to gastric band procedure K95.09, other complications of gastric band procedure K95.81, infection due to other bariatric procedure K95.89, other complications of other bariatric procedure Add codes - are used in case of infection to specify the type of infection or organism or sepsis and bacterial or viral infection agents

question

Acute kidney failure

answer

Sudden failure of renal function following a severe insult to the kidneys

question

renal failure

answer

N17.9, acute N18.9, chronic --also-- end stage (chronic) A condition in which the kidneys lose the ability to remove waste and balance fluids.

question

renal insufficiency

answer

N28.9, acute N18.9, chronic A poor function of the kidneys that may be due to a reduction in blood-flow to the kidneys caused by renal artery disease.

question

Chronic kidney disease

answer

Long term disability of the renal function

question

Nephropathy

answer

General term indicating that renal disease is present

question

Ureter

answer

Carrys urine from the kidneys to the bladder

question

Urethra

answer

Carrys urine from the bladder to the outside of the body

question

Infections of the genitourinary tract

answer

Urethritis - lower UTI Cystitis - lower UTI pyelonephritis - upper UTI A36.85, Diphtheritic A56.01, Chlamydial A59.03, cystitis due to trichomonas N30.00 + B96.4, acute cystitis due to proteus infection N11.9 + B96.20, chronic pyelonephritis due to e.coli N39 .0, urinary tract infection, site not specified ... UTI secondary to indwelling urinary catheter: T8 3.51 -, infection and inflammatory reaction due to in dwelling urinary catheter AND N39 .0, urinary tract infection, site not specified

question

Hematuria

answer

...blood in the urine R31.0, gross hematuria R31.1, benign essential microscopic hematuria R3 1.2, other microscopic hematuria R3 1.9, unspecified hematuria Note - microscopic hematuria should not be confused with hemoglobinuria R8 2.3, an abnormal finding - refers to the presence of free hemoglobin in the urine Note - N30, cystitis codes provide fifth character identifying whether hematuria is present or not

question

Urinary incontinence

answer

N39 .3, stress incontinence (female) (male) R3 9.81, functional urinary incontinence F9 8.0, enuresis not due to substance or known physiological condition N39 .4, other specified urinary incontinence N39 .46, mixed incontinence (male) (female) N32 .81, overactive bladder Note - when underlying causes of incontinence is known - code for that condition should be sequenced first

question

PCS coding / Urinary incontinence treatments

answer

3E0K3GC, introduction of other therapeutic substance into genitourinary tract, percutaneous approach 0TSC0ZZ, reposition bladder neck, open approach 0TSD4ZZ, Reposition urethra, percutaneous endoscopic approach 0TUC7KZ, supplement bladder neck with non autologous tissue substitute comma via natural or artificial opening 0TQDXZZ, repair urethra, external approach

question

Renal disease

answer

N00 - N29 N15.9, infection of the kidney NOS

question

Chronic kidney disease [CKD]

answer

CM classified CKD on the basis of severity - based on the glomerular filtration rate [GFR] N18, chronic kidney disease [CKD] 4th char sub codes: N18.1, CKD, stage 1 N18.2, CKD, stage 2 (mild) N18.3, CKD, stage 3 (moderate) N18.4, CKD, stage 4 (severe) N18.5, CKD, Stage 5 N18.6, end-stage renal disease [ESRD] N18.9, CKD, unspecified N18.9, chronic renal insufficiency, unspecified N18.9, chronic renal failure, unspecified Note - a patient with CKD Stage 5 documented as required chronic dialysis is to be combo coded N18.6 + Z99.2 instead of N18.5

question

Coding / ESRD

answer

N18.6, end-stage renal disease [ESRD] ...defined by the clinicians as the point at which regular dialysis sessions or a kidney transplant is required to maintain life. Add code - Z99.2, dependence on renal dialysis Note - if both a stage of CKD and ESRD are documented for the same patient - only code for ESRD Note - Z94.0, may be asigned with the appropriate CKD code to indicate that a CKD patient is status post kidney transplant

question

Complications of kidney transplant

answer

T86.1 -

question

Acute kidney failure

answer

N17.-

question

Acute renal insufficiency

answer

N28.9

question

Genitourinary system / complications

answer

N99.89, other post-procedural complications and disorders of genitourinary system

question

Kidney failure, unspecified

answer

N19

question

Traumatic injury to the kidney

answer

S37.0, traumatic injury to the kidney Note - care should be taken to determine whether the documentation refers to a traumatic injury to the kidney or to a non traumatic event which is actually acute kidney failure

question

Non traumatic acute kidney injury

answer

N17.9, acute kidney failure, unspecified

question

Acute kidney failure with hypertension

answer

N17, acute kidney failure add code: for hypertension I12.9 + N18.9, Hypertensive kidney disease with chronic kidney disease I13.10 + N18.3, Hypertensive heart and kidney disease with chronic kidney disease, stage 3 I13.2 + N18.5 + I50.9, Hypertensive heart and kidney disease with Stage 5 chronic kidney disease and congestive heart failure N17.9 + I10, Acute kidney failure; hypertension

question

Hypertensive CKD and hypertensive heart and CKD and the applicable CKD stages

answer

I12.0, I13.11, I13.2 Add CKD stage code required - N18.5 - N18.6 I12.9, I13.0, I13.10 Add CKD stage code required - N18.1 - N18.4, N18.9

question

diabetic kidney complications

answer

E08 - E13 Add code: -.21 for diabetic nephropathy Add code: -.22 for chronic kidney disease Add code: -.29 for other kidney complication

question

kidney disease / hypertension and diabetes mellitus

answer

I12 - I13 Add code: E08 - E13 Add code: -.2 Add code: from N18 for stage of chronic kidney disease E11.21, diabetic nephrosis I12.9 + E10.22 + N18.4, chronic kidney disease stage 4 due to hypertension and type 1 diabetes mellitus E10.22, chronic kidney dieasea, unspecified, due to type 1 diabetes mellitus

question

Renal dialysis treatments

answer

Z49.01, Encounter for fitting and adjustment of extracorporeal dialysis catheter Z49.02, Encounter for fitting and adjustment of peritoneal dialysis catheter Z49.31, Encounter for adequacy testing for hemodialysis Z49.32, Encounter for adequacy testing for peritoneal dialysis Z99.2, Dependence on renal dialysis Z91.15, Patient non-compliance with renal dialysis

question

PCS coding / Peritoneal dialysis

answer

0W1G3J4, Bypass peritoneal cavity to cutaneous with synthetic substitute, percutaneous approach 3E1M39Z, Irrigation of peritoneal cavity using dialysate, percutaneous approach

question

PCS coding / Hemodialysis

answer

5A1D60Z, Performance of urinary filtration, multiple

question

PCS and CM coding / Hemodialysis via catheter

answer

5A1D00Z, Dialysis, single encounter ... When dialysis is performed during the same episode of care 5A1D60Z, Dialysis, multiple encounter ... When dialysis is performed during the encounter N18.6 + Z99.2 + 0JH63XZ, Patient with ESRD admitted for insertion of a port-a-cath anchored in a subcutaneous pocket in the chest Z49.01 + N18.6 + Z99.2 + 5A1D00Z, Patient with CKD, Stage 5, on chronic dialysis, admitted for cleansing of hemodialysis catheter, single hemodialysis performed

question

PCS coding / Arteriovenous graft

answer

Root operation - bypass 03180JD, Bypass left brachial artery to upper arm vein with synthetic substitute, open approach

question

PCS coding / Arteriovenous fistula

answer

Root operation - bypass 03180ZD, Bypass left brachial artery to upper arm vein, open approach ... A non maturing or non developing fistula is considered a mechanical complication and is coded as such: T82.590- , Other mechanical complication of surgically created arteriovenous fistula T82.510- , AV fistula breakdown T82.520- , AV fistula displacement T82.530- , AV fistula leakage T82.4, mechanical complications of vascular dialysis catheter

question

Complications of cystostomy

answer

N99.51- N99.511, Infection of cystostomy Add code - specify type of infection: L02.211, abscess of the abdominal wall L03.311, cellulitis of the abdominal wall N99.512, Malfunction of cystostomy N99.518, Other complications of cystostomy T83.0- , mechanical complication of indwelling urinary catheter

question

Cystoscopy as operative approach

answer

Root operation - inspection 0TJB8ZZ, Inspection of bladder, via natural or artificial opening endoscopic

question

Removal of urinary calculus- fragmentation

answer

Root operation - fragmentation 0TF6XZZ, Fragmentation in right ureter, external approach

question

Removal of urinary calculus - extirpation

answer

Root operation - extirpation 0TC78ZZ, Extirpation of matter from left ureter, endoscopic approach

question

Prostate / neoplasms

answer

N40 - N42 C61, Malignant neoplasm of the prostate D29.1, Benign neoplasm of the prostate D07.5, In situ plasm of the prostate

question

Diseases of the male genital organs

answer

N40 - N53

question

Prostate / hyperplasia

answer

N40, Hyperplasia of the prostate 4TH CHAR: providing additional specificity regarding presence or absence of lower urinary tract symptoms Add code - to identify associated symptoms: R39.14, Incomplete bladder emptying R35.1, Nocturia R39.16, Straining on urination R35.0, Urinary frequency R39.11, Urinary hesitancy N39.4, Urinary incontinence N13.8, Urinary obstruction R33.8, Urinary retention R39.15, Urinary urgency R39.12, Weak urinary stream

question

Prostate / inflammatory disease

answer

N41.0, Acute prostatitis N41.1, Chronic prostatitis N41.2, Absence of prostate N41.3, Prostatocystitis N41.4, Granulomatous prostatitis N41.8, Other inflammatory diseases of prostate N41.9, Inflammatory disease of prostate, unspecified

question

Prostate / other disorders

answer

N42.0, Calculus of prostate N42.1, Congestion and Hemorrhage of prostate N42.3, Dysplasia of prostate N42.81, Prostatodynia syndrome N42.82, Prostatosis syndrome N42.83, Cyst of prostate N42.89, Other specified disorders of prostate N42.9, Disorder of prostate, unspecified

question

PCS coding / Prostatectomy

answer

Root operation - resection ... Complete prostate removal Root operation - excision ... Portion prostate removal Root operation - destruction ... in a radical prostatectomy 3 codes are required: Code for prostate resection Code for bladder resection Code for bilateral seminal vessels resection 0VT08ZZ, resection of prostate, via natural or artificial opening endoscopic 0VT00ZZ, resection of prostate, open approach

question

Endometriosis

answer

N80, endometriosis Fourth character - indicating the site N80.1, Endometriosis of the ovary N80.5, Endometriosis of the colon N80.2, Endometriosis of the fallopian tube N73.6, peritubal adhesions of fallopian tubes

question

Genital prolapse

answer

N81.2, Incomplete uterovaginal prolapse N81.3, Complete uterovaginal prolapse N99.3, Prolapse of vaginal vault occurring after a hysterectomy N81.5, Vaginal enterocele N81.4, Prolapse of uterus N81.85, Prolapse of cervical stump O34.522, Prolapse of gravid uterus (2nd trimester) N81.11, Cystocele, midline N81.0, Urethrocele N81.6, Rectocele

question

Endometrial hyperplasia

answer

N85.00, Endometrial hyperplasia, unspecified N85.01, Benign endometrial hyperplasia N85.02, Endometrial intraepithelial neoplasm [EIN]

question

Cervical intraepithelial neoplasia [CIN]

answer

aka: cervical dysplasia ...potentially pre malignant transformation and abnormal growth of squamous cells on the surface of the cervix CIN I: N87.0, mild cervical dysplasia CIN II: N87.1, moderate cervical dysplasia CIN III: D06.- , carcinoma in situ of cervix uteri Note - diagnosis can be made only on the basis of pathological examination of tissues.

question

Vaginal intraepithelial neoplasia [VAIN]

answer

...refers to pre malignant histological findings in the vagina characterized by dysplastic changes VAIN I: N89.0, mild vaginal dysplasia VAIN II: N89.1, moderate vaginal dysplasia VAIN III: D07.2, carcinoma in situ of vagina Note - diagnosis can be made only on the basis of pathological examination of tissues.

question

Vulvar intraepithelial neoplasia [VIN]

answer

...refers to changes that can occur in the skin covering the vulva VIN I: N90.0, mild vulvar dysplasia VIN II: N90.1, moderate vulvar dysplasia VIN III: D07.1, carcinoma in situ of vulva Note - diagnosis can be made only on the basis of pathological examination of tissues.

question

Abnormal cervical or vaginal examination

answer

R87.61- , Abnormal cytological findings in specimens from cervix uteri R87.62- , Abnormal cytological findings in specimens from vagina

question

PCS coding /Hysterectomy

answer

Root operation - resection 0UT94ZZ, Resection of uterus, percutaneous endoscopic approach 0UT9FZZ, laparoscopically assisted vaginal hysterectomy (cervix left intact) ...total laparoscopic hysterectomy: 0UT94ZZ, resection of uterus, percutaneous endoscopic approach + 0UTC4ZZ, resection of cervix, percutaneous endoscopic approach

question

Endometrial ablation

answer

Root operation - destruction 0U5B8ZZ, Destruction of endometrium, via natural or artificial opening, endoscopic

question

Diseases of the breast

answer

N60.11, Fibrocystic disease of the right breast D24.9, Benign neoplasm of female breast D23.5, Benign neoplasm of skin of breast N62, Gynecomastia C50.929, Carcinoma of the male breast C50.919, Carcinoma of the female breast

question

PCS coding / Breast

answer

0HTU0ZZ, Resection of left breast, open approach 07T60ZZ, Resection of left axillary lymphatic, open approach 0KTJ0ZZ, Resection of left thorax muscle, open approach 0HTU0ZZ, Resection of left breast, open approach 07T60ZZ, Resection of left axillary lymphatic, open approach Note - a separate code is not assigned for the resection of the nipple.

question

PCS coding / Modified vs. Radical mastectomy

answer

Radical mastectomy - all or part of the pectoral major and all of the pectoralis minor are removed. Modified radical mastectomy - the pectoralis major is preserved.

question

PCS coding / Tissue expander

answer

Tissue expander is a procedure frequently carried out in conjunction with breast surgery death tissue insertion permits a flap closure of the site making it unnecessary for the patient to undergo a skin graft. Root operation - insertion 0HHT0NZ, Insertion of tissue expander into right breast, open approach

question

Mastectomy / delayed reconstruction

answer

Z42.1, Encounter for breast reconstruction following mastectomy

question

Mammoplasty / reduction

answer

N62, Hypertrophy of breast

question

Mammoplasty / cosmetic increase

answer

Z41.1, Encounter for cosmetic surgery

question

PCS coding / Breast reconstruction

answer

0HRT0JZ, Replacement of right breast with synthetic substitute, open approach 0HRU075, Replacement of left breast using latissimus dorsi myocutaneous flap, open approach 0HRUX7Z, Replacement of left breast with autologous tissue substitute, external approach 0KXH0ZZ, Transfer right thorax muscle, open approach 0KXL0Z6, Transfer left abdomen muscle, transverse rectus abdominis myocutaneous, open approach 0HRV079, Replacement of bilateral breast using gluteal artery perforator flap, open approach 0HRW0JZ, Replacement of right nipple with synthetic substitute, open approach

question

PCS coding note / Breast reconstruction

answer

Note - "reconstruction" references root operations: "Repair" "Replacement" "Supplement" ...root operation - "transfer" is also used for some breast "reconstruction".

question

Breast reconstruction / deformity and disproportion

answer

N65.0, Deformity of reconstructed breast N65.1, Disproportion of reconstructed breast

question

Breast reconstruction / complications

answer

T85.41x- , Breakdown mechanical of breast prosthesis and implant T85.44x- , Capsular contracture of breast implant T85.42x- , Displacement of breast prosthesis and implant T85.43x- , Leakage of breast prosthesis and implant

question

PCS coding / Breast implant removal

answer

root op - "removal" 0HPT0JZ, Removal of synthetic substitute from right breast, open approach

question

Breast implant / removal

answer

Z45.81- , Encounter for adjustment or removal of breast implant

question

Example: Ruptured breast implant

answer

Patient experiences a ruptured breast implant on the left side and is admitted for open removal of the implant and insertion of new implant. Principal diagnosis: T85.41xA, Breakdown mechanical of breast prosthesis and implant, initial encounter Surgery performed: 0HPU0JZ, Removal of synthetic substitute from left breast, open approach + 0HRU0JZ, Replacement of left breast with synthetic substitute, open approach

question

Example: Painful capsule

answer

A patient who had undergone a previous right mastectomy with a breast implant inserted at the time of surgery suffers from a painful capsule. Principal diagnosis: T85.84xA, Pain due to internal prosthetic devices, implants and grafts, not elsewhere classified, initial encounter Surgery performed: 0HPT0JZ, Removal of synthetic substitute from right breast, open approach + 0HRT0JZ, Replacement of right breast with synthetic substitute, open approach

question

Example: Elective implant removal

answer

Patient had undergone bilateral breast implantation 3 years ago. Now admitted for elective implant removal. Patient had no related problems but had become concerned of possible illnesses. Principal diagnosis: Z45.811, Encounter for adjustment or removal of right breast implant + Z45.812, Encounter for adjustment or removal of left breast implant Surgery performed: 0HPT0JZ, Removal of synthetic substitute from right breast, open + 0HPU0JZ, Removal of synthetic substitute from left breast, open

ICD-10-CM/PCS Coding Handbook Chap 20 & 21 – Flashcards

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