chapter 9

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School

Valencia College *

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MISC

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Mechanical Engineering

Date

Feb 20, 2024

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objective The root operation refers to the _________ of the procedure. full definition To determine the appropriate root operation, the ____ __________ of the root operation as contained in the PCS Tables must be applied. not coded separately Components of a procedure specified in the root operation definition or explanation as integral to that root operation are ___ _____ __________. not coded separately Procedural steps necessary to reach the operative site (such as incision or approach) and to close the operative site (such as suturing) also are ___ _____ __________, including anastomosis of a tubular part. replacement procedure If an excision or resection of a body part is followed by a ___________ _________, code both procedures to identify each distinct objective, except when the excision or resection is considered integral and preparatory for the replacement procedure. different body parts During the same operative episode, multiple procedures are coded if: A. The same root operation is performed on _________ ____ _____ as defined by distinct values of the body part character.

repeated During the same operative episode, multiple procedures are coded if: B. The same root operation is ________ in multiple body parts, and those body parts are separate and distinct body parts classified to a single ICD-10-PCS body part value. distinct objectives During the same operative episode, multiple procedures are coded if: C. Multiple root operations with ________ __________ are performed on the same body part. converted During the same operative episode, multiple procedures are coded if: D. The intended root operation is attempted using one approach but is _________ to a different approach. Z53.31 There are four ICD-10-CM diagnosis codes available to identify procedures converted to open procedures. They may only be used as additional diagnosis codes. 1. ______ Laparoscopic surgical procedure converted to open procedure Z53.32

There are four ICD-10-CM diagnosis codes available to identify procedures converted to open procedures. They may only be used as additional diagnosis codes. 2. ______ Thoracoscopic surgical procedure converted to open procedure Z53.33 There are four ICD-10-CM diagnosis codes available to identify procedures converted to open procedures. They may only be used as additional diagnosis codes. 3. ______ Arthroscopic surgical procedure converted to open procedure Z53.39 There are four ICD-10-CM diagnosis codes available to identify procedures converted to open procedures. They may only be used as additional diagnosis codes. 4. ______ Other specified procedure converted to open procedure root operation If the intended procedure is discontinued or otherwise not completed, code the procedure to the ____ _________ performed. discontinued If a procedure is ____________ before any other root operation is performed, code the root operation "Inspection" of the body part or anatomical region inspected.

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performed When a procedure is considered to have "failed" because it did not achieve the hoped-for result, or because every objective of the procedure could not be accomplished, the procedure is coded as _________. complication Failure to achieve the therapeutic objective is not classified as a ____________ of the procedure. attempted It is important to distinguish a "failed" procedure from an "attempted unsuccessful" procedure. If a procedure is ________ but not successful, the procedure would not be coded. microscopic Biopsy: Taking of tissue from a living person for the purpose of ___________ study. lesion A biopsy code is not assigned when a ______ removed for therapeutic purposes is sent to the laboratory for examination, even though the term "biopsy" may be used in describing the procedure. performed Biopsies may be coded with several different root operations depending on how the biopsy was _________. For example, biopsies may be reported with the root operations "Excision," "Extraction," or "Drainage" with the qualifier "diagnostic."

extraction For fine needle aspiration (FNA) of tissue, such as lymph tissue, - Report "__________" of the body part for the tissue aspirated when available in the appropriate ICD- 10-PCS table. excision For fine needle aspiration (FNA) of tissue, such as lymph tissue, - Report "________" if appropriate body part value is not available under "Extraction." drainage For fine needle aspiration (FNA) of gas or fluid report root operation "________." definitive treatment If a diagnostic Excision, Extraction, or Drainage procedure (biopsy) is followed by a more definitive procedure, such as Destruction, Excision, or Resection at the same procedure site, both the biopsy and the more __________ _________ are coded. deepest layer If the root operations such as Excision, Extraction, Repair, or Inspection are performed on overlapping layers of the musculoskeletal system, the body part specifying the _______ _____ is coded. some, all

Root operations to take out ____ or ___ of a body part: - excision - resection - detachment - destruction - extraction a portion "Excision" is defined as cutting out or off, without replacement, "_ _______" of a body part. all "Resection" is cutting out or off, without replacement, "___" of a body part. resection _________ of the specific body part is coded whenever all of the body part is cut out or off; excision of a less specific body part is not coded. detachment "__________": Used exclusively for extremity amputation procedures at any level. detachment Body part value is the site of the __________, with a qualifier, if applicable, to further specify the level where the extremity was amputated.

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destruction "___________": Physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent. None of the body part is physically taken out. extraction "__________": Pulling or stripping out or off all or a portion of a body part by use of force. When the extraction procedure is a biopsy, the qualifier "diagnostic" is used. extirpation Root operations to take out solids/fluids/gases from a body part: - drainage - ___________ - fragmentation drainage "________" takes or lets out fluids or gases. extirpation "___________" takes or cuts out solid matter from a body part. fragmentation "_____________" breaks solid matter into pieces.

biopsies The qualifier "diagnostic" is used to identify "Extraction" or "Drainage" root operations that are ________. drainage device A separate procedure to put in a drainage device is coded to the root operation "Drainage" with the device value "________ ______" extirpation "___________": The solid matter may be an abnormal by-product of a biological function or a foreign body; it may be embedded in a body part or in the lumen of a tubular body part. physical force "Fragmentation": The ________ _____ (e.g., manual, ultrasonic) applied directly or indirectly is used to break the solid matter into pieces. cutting, separation Root operations involving _______ or __________ only: - division - release division "________": Cutting into/separating a body part. - Performed within a body part.

- All or a portion of the body part is separated into two or more portions. release "_______": Freeing a body part from an abnormal physical constraint. - Performed around a body part. - Some of the restraining tissue may be taken out, but none of the body part is taken out. freed In the root operation "Release," the body part value to be coded is the body part being _____ and not the tissue being manipulated or cut to free the body part. release If the sole objective of the procedure is freeing a body part without cutting the body part, the root operation is "_______." division If the sole objective of the procedure is separating or transecting a body part, the root operation is "________." transplantation "_______________": Putting in a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part. reattachment

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"____________": Putting back in, or on, all or a portion of a separated (detached) body part to its normal location or other suitable location. transfer "________": Moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part. multiple For procedures involving transfer of ________ tissue layers including skin, subcutaneous tissue, fascia or muscle, the procedure is coded to the body part value that describes the deepest tissue layer in the flap, and the qualifier can be used to describe the other tissue layer(s) in the transfer flap. reposition "__________": Moving a body part to normal or other suitable location. transfer "________"—the body part will take over or replace the function of a body part. reposition "__________"—the body part will be moved to where it should normally be located, or moved to another appropriate position. tubular body parts ICD-10-PCS defines _______ ____ _____ as the hollow body parts that provide a route of passage for solids, liquids, or gases.

Include the cardiovascular system and body parts in the gastrointestinal, genitourinary, biliary, and respiratory tracts. restriction "___________": Partially close, or narrow, the diameter of an orifice or a lumen. occlusion "_________": Completely close an orifice or a lumen. dilation "________": Expand or enlarge the diameter of the orifice or lumen of a tubular body part. bypass "______": Alter the route of passage of the contents of a tubular body part. natural, artifically created "Restriction," "Occlusion," "Dilation": The orifice may be a _______ orifice or an ____________ _______ orifice. Include intraluminal and extraluminal methods. bypass "______": May include rerouting contents of a body part to a downstream area of the normal route, to a similar route and body part, or to an abnormal route and dissimilar body part.

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. insertion "_________": Putting in a nonbiological device that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part. replacement "___________": Putting in a device that replaces a body part. supplement "__________": Putting in a device that reinforces or augments a body part. change "______": Exchanging a device without cutting/puncturing. removal "_______": Taking out a device from a body part. Coded only when it is not an integral part of another root operation. revision

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"________": Correcting a malfunctioning or displaced device. Do not code the removal of an old device separately. inspection "__________": Visual or manual exploration of some or all of a body part. map "___": To locate electrical impulses or functional areas in a body part. distal If multiple tubular body parts are inspected, the most ______ body part (the body part farthest from the starting point of the inspection) is coded. entire If multiple nontubular body parts in a region are inspected, the body part that specifies the ______ area inspected is coded. coded separately When both an Inspection procedure and another procedure are performed on the same body part during the same episode, and the Inspection procedure is performed using a different approach than the other procedure, the Inspection procedure is _____ __________. control "_______" is the attempt or effort to locate and stop postsurgical hemorrhage or other acute bleeding. Includes irrigation or evacuation of hematoma at the operative site.

repair "______" represents a broad range of procedures for restoring, to the extent possible, a body part to its normal anatomical structure and function. fusion "______" is the joining together of portions of an articular body part, rendering the articular body part immobile. alteration "__________" is coded for all procedures performed solely to improve appearance. creation "________" involves a very narrow range of procedures that are performed for sex change.