pcs mod 3
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School
Rasmussen College, Saint Cloud *
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Course
1126C
Subject
Medicine
Date
Feb 20, 2024
Type
docx
Pages
10
Uploaded by KidToad3548
1.
Question 1
1 Point
A patient had a portion of the pancreas removed for biopsy via FNA (fine needle aspiration). The PCS code for this procedure is:
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2.
Question 2
1 Point
Laparoscopic partial splenectomy. The PCS code for this procedure is:
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3.
Question 3
1 Point
Percutaneous drainage of left axillary lymph node. The PCS code for this procedure is
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4.
Question 4
1 Point
Insertion of pacemaker lead into right ventricle. The PCS code for this procedure is:
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5.
Question 5
1 Point
Code the following case study. One code is required.
Preoperative Diagnosis: Age-related cataract of right eye
Postoperative Diagnosis: Age-related cataract of right eye
Procedure: Cataract removal and insertion of lens
Lens: Bausch and Lomb MX60E, Power +21.5 diopter, serial number: 1234567 EOXP
Procedure Notes: The patient was brought to the operating room and prepped and draped in the usual sterile manner. A wire lid speculum was placed in the eye. The anterior chamber was filled with viscoelastic and a corneal incision was made. The anterior chamber was entered with the Utrata forceps. Mechanical dilation was performed, and the lens was freed. Phacoemulsification was performed with the Nagahara chopper in a stop and go fashion. All cortical material was removed. A 21.5 diopter MX60E lens was placed. The wounds were hydrated and the pupil was noted to constrict equally and round. Lid speculum was removed. Vigamox were given to the patient who left the operating room in good condition.
ICD-10-PCS code:
6.
Question 6
1 Point
Neurolysis of the right median nerve utilizing a needle through the skin. The PCS code for this procedure is:
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7.
Question 7
1 Point
Code the following case study. One code is required.
Preoperative Diagnosis: Low back pain with lumbar facet arthropathy, lumbar radiculopathy
Postoperative Diagnosis: Low back pain with lumbar facet arthropathy, lumbar radiculopathy
Procedure: Spinal Cord Stimulator implant with neural modulation. (Code only the lead implant)
Procedure Notes: The patient was placed in the prone position and the back was aseptically prepped and draped. A local anesthesia was given. An epidural needle was then guided under fluoroscopic guidance to reach the epidural space by loss of resistance technique. The needle was then advanced to T8-9 level. The
stimulator was analyzed, had good coverage of all her painful spots, the lead was
anchored by extending the incision at the Para spinal area around L1-2 and then lead was anchored in the spinal canal with 2-0 silk. Dr. X did the pocket for the generator and completed the implant. The patient was discharged uneventfully. (Be careful with the body part on the implant. Read the documentation carefully.)
ICD-10-PCS code (for the spinal cord stimulator lead implant):
8.
Question 8
1 Point
A patient has a portion of the sigmoid colon removed via an open approach. The PCS code for this procedure is: Blank 1
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9.
Question 9
1 Point
Bone marrow aspiration biopsy obtained via needle from posterior iliac crest, left side. The PCS code for this procedure is: Blank 1
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10.
Question 10
1 Point
Open excision of the entire right axillary lymph node chain. The PCS code for this procedure is: Blank 1
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11.
Question 11
1 Point
Total thymectomy performed via open approach. The PCS code for this procedure is
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12.
Question 12
1 Point
A patient had an open colostomy performed from the descending colon to the abdominal wall. The PCS code for this procedure is:
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o
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13.
Question 13
1 Point
Percutaneous drainage of a cyst of the right auricle of the ear. The PCS code for this procedure is: Blank 1
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14.
Question 14
1 Point
Laparoscopic right adrenalectomy. The PCS code for this procedure is
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15.
Question 15
1 Point
Repair of laceration sclera of right eye. The PCS code for this procedure is:
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16.
Question 16
1 Point
A physician removes a small Lego from a child’s right nostril using forceps.
The PCS code for this procedure is:
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17.
Question 17
1 Point
The patient had the distal portion of the right lower (inferior) parathyroid removed using an open approach. The PCS code for this procedure is:
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18.
Question 18
1 Point
A tracheostomy formation is performed using an open approach. The PCS code for this procedure is: Blank 1
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19.
Question 19
1 Point
Harvesting of the right internal mammary artery (to be used for a graft), open approach. The PCS code for this procedure is: Blank 1
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20.
Question 20
1 Point
A patient had a gastroscopy done for diagnostic purposes. The PCS code for this procedure is:
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21.
Question 21
1 Point
A mitral valve replacement is done using a porcine valve via a sternotomy. The PCS code for this procedure is:
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22.
Question 22
1 Point
Code the following case study. One code is required.
Preoperative Diagnosis: Sensorineural hearing loss
Postoperative Diagnosis: Sensorineural hearing loss
Procedure: Right cochlear implant that is a nucleus contour advance multi-
channel device
Procedure Notes: A general endotracheal anesthetic was administered. The right ear was examined and there was no evidence of ear infection.
The right ear and face were prepped and draped in the standard sterile fashion. An extended postauriclar incision (small incision made in the right inner ear) was created and brought down to the subgaleal level. Flaps were elevated and periosteal incisions
were designed. The mastoid was widely exposed. A recess was created to accommodate the receiver/stimulator case. Mastoidotomy was then performed. The area of the aditus was identified and the short process of the incus exposed. The facial recess was opened. The promontory was identified. The
stapes and the area of the oval window was exposed as was the round window niche. A cochleostomy was performed. Holes were created at the lateral aspect of the receiver/stimulator recess and the mastoidotomy.
The wound was irrigated
copiously with sterile saline. The device was then introduced into the field and secured in the recess. The ground electrode was placed deep to the temporalis fascia. The electrode array was inserted, and a complete insertion was obtained with an advance off stylet technique. The cochleostomy was packed with soft tissue from the lateral incision. The stylet was removed, and the wound was closed. (There are multiple steps to a cochlear implant but only 1 code is needed as these steps are all considered part of the procedure.)
ICD-10-PCS code:
23.
Question 23
1 Point
Recession of left superior rectus muscle for a patient with hypertropia, open approach. The PCS code for this procedure is: Blank 1
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M132/HIM1126C Section 03 ICD-PCS Coding (5.5 Weeks) - Online Plus - 2024 Winter Quarter Term 1
Module 3 Body Systems
Module 3 Body Systems
It is essential to know the anatomy and physiology of the body systems that are included in this module.
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Sense Organs
In PCS, the sense organs
are divided into two body systems:
Eye
Ear, nose, and sinus
Respiratory System
The respiratory system
is divided into two body systems:
Respiratory system
Mouth and throat
The respiratory system contains the trachea, carina, bronchus, lungs, pleura, and diaphragm.
The mouth and throat body system includes the lips, palate, buccal mucosa, gingiva, tongue, parotid gland, salivary gland, parotid duct, sublingual gland, submaxillary gland, pharynx, uvula,
tonsils, adenoids, epiglottis, larynx, vocal cords, and teeth.
Circulatory System
The circulatory system
is divided into five body systems in PCS:
Heart and great vessels
Upper arteries
Upper veins
Lower arteries
Lower veins
The dividing line between upper and lower body arteries and veins is the diaphragm.
Gastrointestinal System
The Gastrointestinal
system includes the esophagus, stomach, small and large intestines, rectum, and anus.
Hepatobiliary is defined as the liver and bile ducts. The Hepatobiliary
system includes the liver, gallbladder, and pancreas, as well as the hepatic and cystic ducts and the common bile duct.
Endocrine System
The Endocrine
system includes the pituitary gland, the pineal body, the thyroid, and parathyroid glands.
Lymphatic and Hemic Systems
The Lymphatic
and Hemic
systems are classified together in one body system value in PCS. These body part values include lymph nodes, thymus, spleen, and bone marrow.
M132/HIM1126C Section 03 ICD-PCS Coding (5.5 Weeks) - Online Plus - 2024 Winter Quarter Term 1
Module 3 Reading Inpatient Documentation for Accurate Coding
Module 3 Reading Inpatient Documentation for Accurate Coding
The key to translating inpatient procedural documentation into accurate ICD-10-
PCS codes is realizing that the documentation provided by the physician may not
match precisely to the terminology used in the PCS coding system. It is the job of
the coder to translate the documentation from the physician into the code that matches most specifically. For this reason, it is essential to have a background in medical terminology, pathophysiology, and anatomy and physiology.
The PCS Coding system has standardized medical terminology. However, that does not mean that physicians are currently using that standardized medical terminology. They may be using familiar terminology that, while not being the same as PCS terminology, has the same meaning. One of the harder parts of reading inpatient procedure documentation for coding is to crosswalk
the
physician documentation into PCS terminology and then identify the most accurate PCS code.
As you recall, the provider does not have to document the exact terms that match the PCS terms as they appear in root operations or other character values of the code. It will be the coder's responsibility to interpret the documentation to match the terms in a code. This will be very important when it comes to determining the objective of the procedure to determine the root operation.
The objective of the procedure is the critical link to finding the correct code. Therefore, it will be your job as the coder to make sure you understand what the documentation is conveying and then translate that into the objective of the procedure. You will not be able to depend on the physician to tell you that in exact words.
Here are the key steps and tips to follow when completing inpatient procedural coding:
o
Make sure you understand all terms being used by the physician before picking a code.
o
Make sure you understand the big picture of the procedure in the context of the documentation to choose the correct objective for the root operation.
o
Use your resources to be sure you are clear on the definition of the root operation, the anatomy, and the guidelines to use. Always double-check.
o
Once you have chosen a code, double-check your coding choices in the Code Table.
o
When you enter a code, double-check you have entered the code correctly. With PCS codes, it is easy to make an entry mistake.
o
Review your documentation to make sure you have caught all procedures to be coded. It is easy to miss the small procedures. When coding procedures from inpatient documentation, look for the actual procedures done. Often these are found in Operative Notes, Progress Notes, or Procedural Notes.
o
You may also find indications of procedures in other parts of the chart, such as MRI imaging. There are many variations from facility to facility on what procedures are coded for an inpatient chart. You will need to ask for that information if you are a new inpatient coder, and it is not provided during your training period.
PCS can be difficult as you need a good understanding of human anatomy and medical
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terminology. There are no shortcuts! Be sure to review the definitions of the root operations and understand the purpose of a procedure before you start to code.
The key is to figure out the intent of the procedure-for example, the insertion of a chest tube. You may first think the root operation is obviously insertion. Insertion
is defined as putting in a
nonbiological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part. Therefore, insertion does not fit the intent
of this procedure. The purpose of the chest tube is to drain the fluid from the chest cavity. The root operation for a chest tube insertion is Drainage
. The drainage root operation is defined as taking or letting out fluids and/or gasses from a body part. To become a successful coder, you must carefully consider the intent and purpose of the procedures you code.
Some choices for root operations depend on the extent of the surgery. When a cataract is removed but no prosthetic intraocular lens is inserted, the root operation is Extraction
. Extraction is defined as pulling or stripping out or off all or a portion of a body part by the use of force. If the lens removal is performed in the same operative episode as the intraocular lens insertion, then the root operation is Replacement
.
Another tricky root operation is the Transplantation versus Replacement choice. Surgeons will document cornea transplant procedures, which code to the root operation of Replacement
in
PCS. The cornea is a body part of the eye. Replacement
is defined as putting in or on a biological or synthetic material that physically takes the place and/or function of all or a portion of a body part. Transplantation
is defined as putting in or on all or a portion of 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. Providers will also document bone marrow transplants
while PCS classifies these into the administration
section (not the medical surgical section). Refer to Coding guideline B3.16. Administration procedures are found in Section 3 of the codebook.