2012 ICD-10-PCS Coding Exercises Answers Part 3
1. Answer:
0P8M0ZZ Root Operation: Division Division, Carpal, Right (0P8M) 0P8M0ZZ Root Operation: Division Division, Carpal, Right (0P8M)
Rationale: Section Medical and Surgical 0 Body System Upper Bones P Root Operation Division 8 Body Part Carpal, Right M Approach Open 0 Device No Device Z Qualifier No Qualifier Z
Index: Osteotomy includes Division or Drainage depending on the intent of the procedure. In this case, Division is selected because drainage was not the intent.
See Division, Head and Facial Bones (0N8), see Division, Lower Bones (0Q8), and see Division, Upper Bones (0P8) are all choices. It is necessary to know the location of the capitate to assign the body system. In this case, Upper Bones is selected as the body system. Next, to assign the body part, it is necessary to review Coding Guideline B41.1a. Since capitate is not a choice in the Table, the body part would be the value corresponding to the whole body part. In this case, the capitate is one of the carpal bones of the wrist in the hand. See Appendix A of these training materials to view the Body Part Key.
Note: The Alphabetic Index can also be used to locate the correct body part value for the capitate bone. Index: Capitate bone, use Carpal, Right.
Rationale: Section Medical and Surgical 0 Body System Upper Bones P Root Operation Division 8 Body Part Carpal, Right M Approach Open 0 Device No Device Z Qualifier No Qualifier Z
Since the lunate is not a choice in the Table, the body part would be the value corresponding to the whole body part. In this case, the lunate is also one of the carpal bones of the wrist in the hand. See Appendix A of these training materials to view the Body Part Key.
Note: The Alphabetic Index can also be used to locate the correct body part value for the lunate bone. Index: Lunate bone, use Carpal, Right.
The same code 0P8M0ZZ is assigned twice because of the Coding Guideline for Multiple Procedures, B3.2.b.
2. Answer: 0L8P3ZZ Root Operation: Division Division, Tendon, Lower Leg, Left (0L8P)
Rationale: Section Medical and Surgical 0 Body System Tendons L Root Operation Division 8 Body Part Lower Leg Tendon, Left P Approach Percutaneous 3 Device No Device Z Qualifier No Qualifier Z
Index: Division
To select the correct body part, it is necessary to know the location of the Achilles tendon. See Appendix A of these training materials. Note: The Alphabetic Index can also be used to locate the correct body part value for Achilles tendon.
Index: Achilles tendon, use Tendon, Lower Leg, Left. The Achilles tendon connects the calf muscle to the calcaneus (heel bone) and is also known as the calcaneal tendon, heel cord- or heel tendon. Coding Guideline B4.5 instructs that when the focus is the tendon, the Tendon body system is used, not Joint.
3. Answer: 0MN14ZZ Root Operation: Release Release, Bursa and Ligament, Shoulder, Right (0MN1)
Rationale: Section Medical and Surgical 0 Body System Bursae and Ligaments M Root Operation Release N Body Part Shoulder Bursa and Ligament, Right 1 Approach Percutaneous Endoscopic 4 Device No Device Z Qualifier No Qualifier Z Index: Release
To identify the body part, knowledge of the anatomy of the ligaments is needed. The coracoacromial ligament extends between the coracoid process and the acromion above the shoulder joint. See Appendix A of these training materials. Index Coracoacromial ligament for reference to the Shoulder Bursa and Ligament. Coding Guideline B4.5 instructs that when the focus is the ligament, the Bursa and Ligament body system is used, not Joint.
Note: The Alphabetic Index can also be used to locate the correct body part value for the coracoacromial ligament. Index: Coracoacromial ligament, use Bursa and Ligament, Shoulder, Right.
4. Answer: 0UN24ZZ Root Operation: Release Release, Ovaries, Bilateral (0UN2) 0UN74ZZ Root Operation: Release Release, Fallopian Tubes, Bilateral (0UN7)
Rationale: Section Medical and Surgical 0 Body System Female Reproductive System U Root Operation Release N Body Part Ovaries, Bilateral 2 Approach Percutaneous Endoscopic 4 Device No Device Z Qualifier No Qualifier Z
Rationale:
Section Medical and Surgical 0 Body System Female Reproductive System U Root Operation Release N Body Part Fallopian Tubes, Bilateral 7 Approach Percutaneous Endoscopic 4 Device No Device Z Qualifier No Qualifier Z Index: Release
There is no Alphabetic Index entry for Freeing. It is important that the root operation definitions in PCS are followed. Release describes this procedure according to the definitions. In this case, there is a value for bilateral procedures and this would be used rather than coding individual (right and left) sites. There are individual body part values for the Fallopian Tubes and Ovaries, so multiple codes are required (Coding Guideline B3.2.a).
5. Answer:
01N50ZZ Root Operation: Release Release, Nerve, Median (01N5)
Rationale: Section Medical and Surgical 0 Body System Peripheral Nervous System 1 Root Operation Release N Body Part Median Nerve 5 Approach Open 0 Device No Device Z Qualifier No Qualifier Z Index: Release
To code the body part, it is necessary to know that the median nerve is released during a carpal tunnel release. The body part value assigned is the structure released (median nerve) and not the structure cut (carpal ligament) to obtain the release, where the two differ. The carpal ligament is cut to release the median nerve, and not for its own sake.