Friday, October 21, 2016

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 5th 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

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:


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:


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:


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. 

Tuesday, August 18, 2015

AIDS/HIV related Dx

AIDS/HIV-related illnesses/Disease
We need to assign 042 as the Principal diagnosis when the patient admitted for treatment of the following conditions
            Candidiasis (thrush)

            Cervical cancer

            CMV (cytomegalovirus)

            Cryptococcal meningitis


            HIV-associated brain impairment

            Kaposi’s sarcoma


            Mycobacterium avium intracellulare

            PCP (pneumocystis pneumonia)



            Tuberculosis (TB)

Saturday, August 8, 2015

Sepsis, Severe Sepsis, Septic Shock

Sepsis, Severe Sepsis, and Sepsis Shock
You will not find many surprises in ICD-10 for the coding of sepsis.  The biggest change is that sepsis – not identified or documented as severe – will require the code for the sepsis.  There will not be an underlying code to indicate SIRS (Systemic Inflammatory Response Syndrome).   It would be code A41.9 if the organism is unknown or the appropriate code from A41.x if the organism is known.   Severe sepsis or sepsis with an organ dysfunction will continue to require a minimum of 2 codes:  a code from category A41.x and a code from category R65.2x and a code for the organ dysfunction, if known. Remember there is not a code for multi-organ dysfunction – each one must be coded individually.

Septic shock represents a type of acute organ dysfunction and the presence of severe sepsis.  For all cases of septic shock, the code for the underlying systemic infection should be sequenced first, followed by code R65.21:  Severe sepsis with septic shock.   This code is assigned even if the term severe sepsis is not documented.  If other acute organ dysfunctions are document it will be coded individually. 

Subcategory R65.2x can never be assigned as a principal diagnosis. Therefore, the underlying systemic infection should be assigned as the principal diagnosis if severe sepsis is present on admission and meets the definition of principal diagnosis.  Be sure to query the physician if the documentation is not clear.  The following represents coding guidelines that have not changed from ICD-9 to ICD-10.

·         If the reason for admission is both sepsis or severe sepsis, and a localized infection such as pneumonia or cellulitis – code(s) for the underlying systemic infection should be assigned first and the code for the localized infection should be assigned as a secondary diagnosis.

·         If the patient has severe sepsis, a code from subcategory R65.2x should also be assigned as a secondary diagnosis.

·         If the patient is admitted with a localized infection, such as pneumonia, and sepsis/severe sepsis does not develop until after admission, then the localized infection should be assigned first, followed by the appropriate sepsis/severe sepsis codes.

The Guideline for sepsis resulting from a procedure has not changed.   If the sepsis is due to or a result of the procedure, the complication of the procedure must be listed as the principal diagnosis (if it meets the definition of principal diagnosis).   Let’s review a few sections from the ICD-10-CM Official Coding Guidelines.

Section D#5, Sepsis due to a postprocedural infection:
Sepsis resulting from a postprocedural infection is a complication of medical care.  
·         T80.2 – Postprocedural infection code.
·         T81.4 – Infections following infusion, transfusion, and therapeutic injection.
·         T88.0 – Infection following a procedure.
·         O86.0 – Infection following immunization.

Infection of obstetric surgical wound should be coded first; followed by the code for the specific infection. If the patient has severe sepsis the appropriate code from subcategory R65.2x,  additional code(s) for any acute organ dysfunction should also be assigned. 

Section D#6, Sepsis and severe sepsis associated with a noninfectious process (condition):
A noninfectious process, such as trauma, may lead to an infection which can result in sepsis or severe sepsis.  If sepsis or severe sepsis is documented as associated with a noninfectious condition, such as a burn or serious injury, and this condition meets the definition for principal diagnosis, then the code for the noninfectious condition should be sequenced first, followed by the code for the resulting infection.

If severe sepsis is present, a code from subcategory R65.2x should be assigned with any associated organ dysfunction(s) codes.  It is not necessary to assign a code from subcategory R65.1x – Systemic inflammatory response syndrome (SIRS) of non-infectious origin – for these cases.  If the infection meets the definition of principal diagnosis it should be sequenced before the non-infectious condition.  Only one code from category R65 should be assigned.

Section D #7, Sepsis and septic shock complicating abortion, pregnancy, childbirth, and the puerperium

The rule has not changed.   Sepsis will be the secondary diagnosis when associated with the above conditions.

Please Note – The term urosepsis should be queried for the classification as it is not to be considered synonymous with sepsis and should no longer default to 599.0 in ICD-10.   Also, the physician should be queried for negative or inconclusive blood cultures as this does not preclude a diagnosis of sepsis in patients with clinical evidence of the condition.  

As always, I hope that this information has been helpful. 

ICD-10-CM, “Official Guidelines for Coding and Reporting “ 2011 (Draft)