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Basic ICD-10-CM/PCS Coding

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Basic ICD-10-CM/PCS 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 4. Main term=Prolapse Introduction to ICD-10-CM M50.20 Prolapse—see Displacement, intervertebral disc, cervical 5. Main term=Stenosis Exercise 1.1 N88.2 Stenosis, endocervical—see Stenosis 1. N63 Mass, breast cervix 2. N13.30 Hydronephrosis (primary) 3. J34.2 Deviated, nasal septum Exercise 1.4 4. R59.0 Adenopathy, inguinal 1. A41.9 Sepsis NOS 5. I25.10 Disease, arteriosclerotic—see 2. A49.8 Infection, bacteroides NEC Disease, heart, ischemic, atherosclerotic. 3. I31.9 Pericarditis (with effusion) Arteriosclerotic heart—see Arteriosclerosis, 4. B08.3 Disease, fifth coronary (artery) Tabular List—B08.3—Erythema 6. G44.209 Headache, tension infectiosum [fifth disease] 7. K85.9 Pancreatitis (suppurative) 5. Dementia, with, Lewy bodies G31.83 8. K00.6 Eruption, tooth abnormal [F02.80] (premature) See the "Use additional code" note under 9. I33.0 Endocarditis, infectious category G31 10. I08.0 Endocarditis, mitral with aortic Use additional code to identify dementia (valve) disease, active or acute with behavioral disturbance (F02.81) Use additional code to identify dementia Exercise 1.2 without behavioral disturbance (F02.80) 1. Nonessential modifier = congenital Q67.8 Distortion (congenital) chest (wall) Exercise 1.5 2. Nonessential modifier=acute 1. Intrahepatic bile duct K57.32 Diverticulitis (acute) intestine, large 2. Diabetes mellitus arising in pregnancy 3. Nonessential modifier = bleeding Gestational diabetes mellitus K64.4 Hemorrhoids external 3. Anorexia nervosa 4. Nonessential modifier=cardiac 4. Blackout, Fainting, Vasovagal attack R01.0 Murmur (cardiac) functional 5. Diverticulum of appendix 5. Nonessential modifier=chronic J32.0 Sinusitis (chronic) maxillary Exercise 1.6 1. I85.11 Varix, esophagus, in, cirrhosis of Exercise 1.3 liver, bleeding 1. Main term=Endomyometritis 2. N39.0 Infection, urinary (tract) N71.0 Endomyometritis—see Endometritis, Use additional code (B95–B97) to identify acute infectious agent 2. Main term=Metrorrhexis B96.20 Infection, Escherichia coli as cause N85.8 Metrorrhexis—see Rupture, uterus, of disease classified elsewhere nontraumatic 3. K26.0 Ulcer, duodenum, acute, with 3. Main term=Osteoarthrosis hemorrhage M19.019 Osteoarthrosis—see also 4. P61.2 Anemia, due to, prematurity Osteoarthritis, shoulder, M19.01- 5. Z04.1 Examination, following, motor (unspecified = M19.019) 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 3. Answer: 041L0KL Introduction to ICD-10-PCS Character Code Explanation Section 0 Medical and Surgical Body 4 Lower Arteries Review Exercises: Chapter 2 Syste 1. Answer: 0DJO8ZZ m Character Code Explanation Root 1 Bypass Oper Section 0 Medical and Surgical ation Body D Gastrointestinal System Body Part L Femoral Artery, Left Syst em Approach 0 Open Root J Inspection Device K Nonautologous Tissue Ope Substitute ratio Qualifier L Popliteal Artery n Body Part 0 Upper Intestinal Tract INDEX: When consulting the Index, the main term Approach 8 Via Natural or Artificial Bypass, subterm Artery, Femoral produced Opening Endoscopic the root operation table of 041. According to ICD-10-PCS guideline B3.6a.Bypass Device Z No Device procedures: Bypass procedures are coded by Qualifier Z No Qualifier identifying the body part bypassed “from” and the body part bypassed “to”. The fourth INDEX: Root Operation: Inspection. Index: character body part specifies the body part Esophagogastroduodenoscopy (0DJ08ZZ) bypassed from, and the qualifier specifies the body part bypassed to. In this example, the In this example, the complete seven bypass was “from” the femoral artery “to” the character code is listed in the Index. The popliteal artery. A cadaver vein graft is the code still must be confirmed using the code device identified as nonautologous (from Tables. EGD is an inspection procedure another human than patient) tissue substitute. when no other procedures, such as a biopsy or excision, are performed with the EGD. 4. Answer: 0UN24ZZ Body part inspected is the upper intestinal Character Code Explanation tract. Approach is through the mouth so “via Section 0 Medical and Surgical natural or artificial opening endoscopic” is the choice for this procedure. Body U Female Reproductive Syste System 2. Answer: 0HBU0ZZ m Character Code Explanation Root N Release Opera Section 0 Medical and Surgical tion Body System H Skin and Breast Body Part 2 Ovaries, Bilateral Root B Excision Approach 4 Percutaneous Endoscopic Oper ation Device Z No Device Body Part U Breast, Left Qualifier Z No Qualifier Approach 0 Open INDEX: Lysis see Release. Release, Ovaries, Device Z No Device Bilateral (0UN2) Definition of release in Qualifier Z No Qualifier ICD10-PCS is freeing a body part from an abnormal physical constraint which also INDEX: When consulting the Index, the main term describes a procedure identified as lysis. Two Mastectomy has two subterms: see Excision, codes are required for this procedure as the Skin and Breast and see Resection, Skin and same root operation is performed on different Breast. Since only part of the breast was body parts as defined by distinct values of the removed, the root operation is Excision. body part character for the root operation “release.” Laparoscopy is an approach that is 6. Answer: 0TP98DZ percutaneous endoscopic Character Code Explanation Section 0 Medical and Surgical Answer: 0UN74ZZ Body System T Urinary System Character Code Explanation Root P Removal Section 0 Medical and Surgical Operation Body U Female Reproductive Body Part 9 Ureter System System Approach 8 Via Natural or Artificial Root N Release Opening Endoscopic Operation Device D Intraluminal Device Body Part 7 Fallopian Tubes, Bilateral Qualifier Z No Qualifier Approach 4 Percutaneous Endoscopic Device Z No Device INDEX: Root Operation: Removal. Index: Qualifier Z No Qualifier Removal of device from, Ureter (0TP9) The objective of the procedure was to take the stent INDEX: Lysis see Release. Release, Fallopian out of the ureter which matches the definition of Tubes (0UN7) “removal” to take out of off a device from a body part. The approach is by cystoscopy or via natural or 5. Answer: 0SG10A1 artificial opening (urethra) endoscopic. A stent is an Character Code Explanation intra-luminal device which are devices placed inside Section 0 Medical and Surgical tubular body parts. Body System S Lower Joints Root G Fusion 7. Answer: 0XMJ0ZZ Operation Character Code Explanation Body Part 1 Lumbar Vertebral Joints, 2 Section 0 Medical and Surgical or more Body X Anatomical Region, Upper Approach 0 Open System Extremities Device A Interbody Fusion Device Root M Reattachment Qualifier 1 Posterior Approach, Operation Posterior Column Body Part J Hand, Right Approach 0 Open INDEX: Root operation is fusion. Index: Fusion, Device Z No Device lumbar vertebrae 2 or more (0SG1). According to Qualifier Z No Qualifier the ICD-10-PCS guideline for fusion procedures of the spine, B3.10a: The body part coded for a spinal INDEX: Root Operation: Reattachment. Index: vertebral joint(s) rendered immobile by a spinal Reattachment, Hand, Right (0XMJ0ZZ) Index fusion procedure is classified by the level of the provides a specific code for this operation. The only spine (e.g. thoracic). There are distinct body part variable on the Table is the body part being values for a single vertebral joint and for multiple reattached. vertebral joints at each spinal level. According to guideline B3.10.c if an interbody fusion device is 8. Answer: 0W9G3ZX used to render the joint immobile (alone or Character Code Explanation containing other material like bone graft), the
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