Module 04 Assignment Worksheet (1) (1)

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Samantha Moore Module 04 Assignment - ICD-10-PCS Coding Principles and Code Build Process Overview: There are 3 parts to this assignment. Each part of the assignment addresses a specific aspect of ICD-10-PCS coding. To code accurately using the ICS-10-PCS system requires the ability to understand and apply the coding principles to clinical documentation by following the designated code build process. Part A: ICD-10-PCS Identify Coding Guidelines The ICD-10-PCS system includes specific conventions and coding guidelines or “rules” which provide instruction on how to accurately construct the codes. This portion of the assignment will provide an opportunity to become more familiar with the guidelines to be used in the determination of the appropriate PCS code. Instructions: Utilize the ICD-10-PCS Official Coding Guidelines presented in the front of the ICD-10-PCS Code Book to match the narrative in the assignment for Part A. Steps: For each coding guideline narrative, 1. Read the narrative in Column 1-Part A in the table below. 2. Match the coding guideline(s) narratives in Column 1-Part A with the Official Coding Guidelines found in the front of the ICD-10-PCS Code Book. 3. Enter the alphanumeric label identifier from the Official Coding Conventions/Guideline(s) in Column 2-Part A of the table in correlation to the coding guideline narrative in Column 1-Part A. If there is more than one applicable Coding Convention or Guideline for the narrative, enter both guideline labels in Column 2-Part A corresponding to the narrative in Column 1-Part A. 4. Reference both A and B conventions and guidelines from The Official Coding Guidelines in the front of the ICD-10-PCS Code Book. Table for Part A - Identify the Official Coding Guideline Column 1-Part A Column 2-Part A ICD-10-PCS Coding Guidelines Coding Guideline Identifiers Page 1 of 8

Example: ICD-10-PCS codes are always composed of 7 characters. A1 1A. It is not required that the provider document using the exact PCS terms. The coder has the responsibility to correlate the clinical documentation stated by the provider to the correct Root Operation definition without querying the provider for clarification. A11 2A. The Code Tables in the code book may be accessed directly or the Alphabetic Index may be used to locate the correct table. It is optional to use the Alphabetic Index, but the PCS Code Tables must always be consulted to determine a valid code. A6 3A. Each of the 7 characters of a PCS codes has a specific “value”. The character can be represented by a number value of 0 – 9 or an alphabetic letter value with the exception of alpha characters O and I to avoid confusion with 0 (zero) and 1 (one). Use of and O or I in a PCS code results in an invalid code. A2 4A. For a PCS code to be valid, the combinations of the 4 th – 7 th character values must all be obtained from the same row in the PCS Code Tables. A9 5A. Components of a procedure that are stated in the Root Operation definition and explanation are NOT coded separately. Also, any procedural steps necessary to reach the operative site and close the operative site, including anastomosis of a tubular body part, are NOT coded separately. B3.1a 6A. Multiple procedures are coded if during the same operative encounter, the same root operation is performed on different body parts as defined by distinct values of the body part character. B3.2 7A. If a procedure is performed on a portion of a body part that does not have a separate body part value, code the body part value corresponding to the whole-body part. B4.1A 8A. The Root Operations Excision, Extraction and Drainage are used for Biopsy procedures along with the Qualifier X-Diagnostic. The X Qualifier is only used for procedures such as biopsies, where the intent of the procedure is to remove a portion of the body part for the purpose of analysis. Documentation that merely states the specimen was sent to Pathology does NOT equate to a diagnostic intent as this is a standard procedure for all removed tissue. B3.4a Page 2 of 8

9A. Bilateral Body Part values are available for a limited number of body parts. If the identical procedure is performed on contralateral body parts and a bilateral body part value is available in the PCS system, a single procedure is coded using the bilateral body part procedure. If no bilateral body part value exists, each procedure is coded separately using the appropriate body part value for each site. B4.3 10A. When the intended Root Operation is attempted using one Approach, but is converted to a different Approach, multiple procedures are coded. B3.2d 11A. Bypass procedures (non-coronary) are coded by identifying the body part bypassed “from” (specify in the 4 th Character Body Part Value) and the body part bypassed “to” (specify in the 7 th Character Qualifier Value). Coronary artery bypass procedures are coded differently than other bypass procedures. The Body Part identifies the number of coronary arteries bypass to and the Qualifier specifies the vessel bypassed from. B3.6a 12A. Root Operations Excision, Extraction, Repair or Inspection performed on overlapping layers of the musculoskeletal system are coded to the Body Part specifying the deepest layer. B3.5 13A. Inspection of a body part(s) performed to accomplish the intent or objective of the procedure is not coded separately. B3.11a 14A. If multiple tubular body parts are inspected, the most distal body part (furthest from the starting point of the inspection) is coded. B3.11b 15A. Procedures performed within an orifice on structures that are visible without the aid of any instrumentation are coded to the Approach External. Procedures performed indirectly by the application of external force through and intervening body layers are coded to the Approach External. B5.3a 16A. A device is coded only if the device remains after the procedure is completed. Materials such as sutures, ligatures, radiological markers and temporary post-operative wound drains are considered integral to the procedure and are not coded as devices. B6.1b 17A. If a procedure is performed on the skin, subcutaneous tissue or fascia overlying a joint, the procedure is coded to a specific body part. B4.6 Page 3 of 8

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18A. The Root Operation Control is defined as “Stopping or attempting to stop post-procedural or other acute bleeding.” If an attempt to stop the bleeding is initially unsuccessful and to stop the bleeding requires a more definitive root operation such as Bypass, Detachment, Excision, Extraction, Reposition, Replacement or Resection, then the more definitive root operation is coded instead of Control. B3.7 19A. Reduction of a displaced fracture is coded to the Root Operation Reposition. The application of a cast or splint in conjunction with a Reposition procedure is not coded separately. Treatment of a non-displaced fracture is coded to the procedure performed. B3.15 20A. In the Root Operation Release, the body part value to be coded is the body part being freed and not the tissue being manipulated or cut to free the body part that is entrapped. B3.13 Part B: ICD-10-PCS Apply Coding Guidelines to Clinical Documentation To accurately assign codes in the ICD-10-PCS coding system, the Official Coding Guidelines need to be applied to the clinical documentation as stated in operative notes. The second part of the assignment requires interpretation of the clinical documentation and application of the coding guideline(s) in order to guide the coder in determining the appropriate PCS code. Instructions: In this portion of the assignment, Column 1-Part B provides scenarios that are to be aligned with the appropriate coding guidelines from the Official Coding Guidelines. Steps: 1. Read the narrative scenario in Column 1-Part B in the table below. 2. Identify the appropriate coding guideline(s) for each scenario and enter the alphanumeric label identifier(s) for the Official Coding Guideline in Column 2-Part B. Table for Part B - Apply Guidelines to Scenarios Column 1-Part B Column 2-Part B Scenarios Indicate Applicable Coding Guideline Identifier Page 4 of 8

Example: 0DTJ0Z only 6 characters is an invalid code per which coding guideline A1 1B. A procedure performed on the skin overlying the wrist joint is coded to the Lower Arm B4.6 2B. A procedure performed on the alveolar process of the mandible is coded to the mandible body part B4.1a 3B. Excisional biopsy of the right breast B3.4a 4B. The provider states that he performed the removal of the entire gallbladder B3.8 5B. Resection of the hip joint in preparation for a total hip replacement B3.18 6B. The coder accessed the PCS Code tables directly bypassing the Alphabetic Index A7 7B. Code assigned: O DTJ0ZZ – Section value “O” is invalid per which coding guideline A2 8B. Excision of a lesion in the ascending colon and excision of a lesion in the rectum B3.2 9B. Excisional debridement through the skin, subcutaneous tissue to the muscle B3.5 10B. Valid Code: 0HHW01Z vs Invalid Code: 0HHWXNZ – character values 4 – 7 must come from the same row in the Code Book A9 11B. 0UL 7 4CZ – Body Part value is an example of which coding guideline B4 12B. Laparoscopic appendectomy converted to open appendectomy B3.2d 13B. Femoropopliteal Bypass Body Part and Qualifier values per guideline B3.6a 14B. Esophagoscopy used in the performance of dilation of the esophagus B5 15B. Device value in a procedure performed to dilate the urethra using a 32 French calibrator B6 16B. Body Part in an EGD (esophagogastroduodenoscopy) exploration via entry through the mouth to the duodenum B4 17B. Root Operation for post-operative hemorrhage with cauterization of a bleeder to stop the bleeding B3.7 Page 5 of 8

18B. Root operation to free a median nerve from entrapment B3 19B. Approach for tonsillectomy or closed reduction of a dislocated fracture B5 20B. Root Operation for the reduction of a displaced fracture B3 Part C: ICD-10-PCS Code Build Process To be an effective coder, one must first have a solid understanding of the ICD-10-PCS system. Learning to code using the ICD-10-PCS Code Book provides the foundation for applying the principles to the code build process. Instructions: Part C of the assignment allows you to build a code step by step identifying each character following a specific decision-making process. Steps: 1. Read the procedural statement provided. 2. Follow the prompts in Column 1 to build the ICD-10-PCS code for the procedure stated. 3. Enter your responses to the Column 1 prompts in Column 2. Be specific and detailed. Procedure: Total Laparoscopic Cholecystectomy. Incidental wound drains remain at the end of the procedure. Column 1 Column 2 Steps to Build the Code Responses 1. State the character value for the starting point to build the 7- character PCS code 0 (ZERO) The first character of a medical and Surgical section is always zero. 2. Enter the Main Term from the procedural statement The main term for the procedural statement Total Laparoscopic Cholecystectomy is Cholecystectomy referring to the resection which is the type of procedure. 3. Research the procedure to determine the intent or objective. Enter the information found on research and your source The intent and objective of a Total Laparoscopic Cholecystectomy. is cutting out without replacement according to the ICD-10-PCS codebook page 277. 4. Locate the Main Term in the Alphabetic Index of the physical ICD-10-PCS Code Book. Enter the information from the Index for the Main Term and include the page number of the index page. Main term Cholecystectomy is located in the ICD-10-PCS alphabetic index page 742. It includes the options of Excision and Resection. Page 6 of 8

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5. Look up the definitions for the Root Operation(s) listed for the Main Term. Enter the complete official definition(s) for the stated root operation(s). On page 855 and 856 of the ICD-10-PCS book the definitions for both excision and resection are the following: Excision: Cutting out or off, without replacement, a portion of a body part. Explanation: The qualifier DIAGNOSTIC is used to identify excision procedures that are biopsies. Resection: Cutting out or off, without replacement, all of a body part. 6. Based on the procedural statement, determine which definition is the best match. Enter that Root Operation and your rationale (reason) for that choice. Resection would be the best root operation due to no statement leading to believe that any biopsies were performed and gallbladder was removed and not replaced. 7. State the first 3 characters of the PCS code for the Root Operation identified in the Alphabetic Index. 0FT is the first three characters identifying the the root operation in the Alphabetic Index on page 742. 8. Locate that table in the PCS Code Book Code Tables. Indicate the page number of the Code Table. Page 277 contains the table for Code 0FT in the PCS Code Book. 9. Based on the procedure definition, state the body part and the corresponding 4 th character value for Body Part from the code table. The gallbladder is the body part which would mean the 4 th character in this code is (4). 10. Research the term for the type of approach stated in the procedural statement. State the definition and your source. The guidelines on page 6 of the ICD-10-PCS codebook explain under B5. Approach Procedures performed using the open approach with percutaneous endoscopic assistance are coded to the approach Open. Example: Laparoscopic-assisted sigmoidectomy is coded to the approach Open. In the Appendix on page 873 of the ICD-10-PCS book the medical and surgical approaches are defined and Open is cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure 11. Based on the information from #9, state the Approach and its definition along with the character value for the 5 th character Approach selected from the code table. The approach in Total Laparoscopic Cholecystectomy is open which is defined as utting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure and the code selected from the table is (0) zero. 12. Based on the procedural statement, is a Device to be coded? Why or why not? State the code character value and description for the 6 th character DEVICE. Based of the procedural statement no device is to be coded when following the surgical table on page 277 of the codebook. Code character would be (Z) which means no device was used. Page 7 of 8

13. Based on the procedural statement, enter the 7 th character value and code character for the Qualifier from the code table. Based on the procedural statement the 7th character would be (Z) using the table on pg 277. 14. State the final 7-character PCS Code as determined via the PCS Code Book code table 0FT40ZZ 15. Complete the code character table (below) by entering the character descriptions and character values for the code stated in #14 (above). An example of a completed table is shown at the bottom of the page. Character 1 Value Character 2 Value Character 3 Value Character 4 Value Character 5 Value Character 6 Value Character 7 Value Section Body System Root Operation Body Part Approach Device Qualifier (0) Medical and Surgical Hepatobiliary System and Pancreas (F) Extirpation (C) Gallbladder (4) Open (0) No Device (Z) No Qualifier (Z) Example of a Medical and Surgical Code: 0DBH8ZX Character 1 Value Character 2 Value Character 3 Value Character 4 Value Character 5 Value Character 6 Value Character 7 Value Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical (0) Gastrointestinal (D) Excision (B) Cecum (H) Via a natural orifice endoscopic (8) None (Z) Diagnostic (X) Page 8 of 8