ICD-10-PCS Root Operation Test

ICD-10-PCS Root Operation Test

ICD-10-PCS Practice Questions:

Root Operations to Take Out Some or All of a Body Part

Excision, Resection, Detachment, Destruction, and Extraction

1.    Sigmoidoscopy with rectal polyp fulguration

Root Operation – Destruction

2.    Laparotomy with complete removal of sigmoid colon

Root Operation – Resection

3.    Left 5^th toe ray amputation at the metatarsal-phalangeal joint

Root Operation – Detachment

4.    Laparoscopic removal of right ovarian cyst

Root Operation – Excision

5.    Diagnostic dilatation and curettage

Root Operation – Extraction

6.    Bone marrow aspiration left iliac crest

Root Operation – Extraction

7.    EGD with gastric biopsy

Root Operation – Excision

8.    L5-S1 discectomy via laminotomy with moderate-sized fragments retrieved

Root Operation – Excision

9.    Left upper lobectomy of lung via thoractom

Root Operation – Resection

10.  TURP (transurethral resection of prostate)

Root Operation – Excision

11.  Open retropubic prostatectomy

Root Operation – Resection

12.  Laparoscopic endometrial ablation

Root Operation – Destruction

13.  Revision of right BKA to AKA

Root Operation – Detachment

14.  Amputation above right knee, distal shaft of femur (Definition of Low:  Amputation at the distal portion of the shaft of the humerus or femur)

Root Operation – Detachment

15.  Cauterization of nosebleed

Root Operation – Destruction

Key:

1.    0D5P8ZZ

2.    0DTN0ZZ

3.    0Y6Y0Z0

4.    0UB04ZZ

5.    0UDB7ZX

6.    07DR3ZX

7.    0DB68ZX

8.    0SB40ZZ

9.    0BTG0ZZ

10. 0VB08ZZ

11. 0VT00ZZ

12. 0U5B4ZZ

13. 0Y670ZZ

14. 0Y6C0Z3

15. 095KXZZ

2017 General Coding Guidelines

2017 ICD-10-CM guidelines - General coding guidelines:

Laterality:

Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side.

When a patient has a bilateral condition and each side is treated during separate encounters, assign the "bilateral" code (as the condition still exists on both sides), including for the encounter to treat the first side.

For the second encounter for treatment after one side has previously been treated and the condition no longer exists on that side, assign the appropriate unilateral code for the side where the condition still exists (e.g., cataract surgery performed on each eye in separate encounters). The bilateral code would not be assigned for the subsequent encounter, as the patient no longer has the condition in the previously-treated site. If the treatment on the first side did not completely resolve the condition, then the bilateral code would still be appropriate.

BMI, Ulcer Depth/Stage, Coma Scale, NIHSS:

BMI, non-pressure chronic ulcer depth, pressure ulcer stage, coma scale, and NIH stroke scale (NIHSS) code assignment may be based on medical record documentation from clinicians who are not the patient’s provider… (e.g., a dietitian often documents the BMI, a nurse often documents the pressure ulcer stages, and an emergency medical technician often documents the coma scale).

The associated diagnosis (such as overweight, obesity, acute stroke, or pressure ulcer) must be documented by the patient’s provider.

The BMI, coma scale, and NIHSS codes should only be reported as secondary diagnoses.

Documentation of Complications of Care:

Complication code assignment is based on the provider’s documentation unless otherwise instructed by the classification.

The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented. 

Code Assignment and Clinical Criteria

2017 ICD-10-CM guidelines – “Code assignment and clinical criteria” Update:

Code assignment and clinical criteria:

The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

Instructions to coders and CDSs:

We always code based on narrative diagnosis documentation from the physician when the documentation appears reliable.

We never code from clinical criteria or clinical indicators alone.

Coders and CDSs must continue to review records to ensure that documentation/clinical indicators support the stated diagnoses.

There must be appropriate clinical criteria/indicators before a query can be initiated.

Instances of potentially unreliable documentation must continue to be addressed per Tenet policy. 

2017 "With" Update

2017 ICD-10-CM guidelines – “With” Update:

“With”

The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List.

The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List.

These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated.

For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related. 

2017 Exclude 1 Update

2017 ICD-10-CM guidelines - Exclude 1 Update:

EXCLUDES 1:

An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note…

An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, query the provider.

For example, code F45.8, Other somatoform disorders, has an Excludes 1 note for "sleep related teeth grinding (G47.63)," because "teeth grinding" is an inclusion term under F45.8. Only one of these two codes should be assigned for teeth grinding.  However psychogenic dysmenorrhea is also an inclusion term under F45.8, and a patient could have both this condition and sleep related teeth grinding. In this case, the two conditions are clearly unrelated to each other, and so it would be appropriate to report F45.8 and G47.63 together.