Updated on: October 9, 2018

100 Tips for ICD-10-PCS Coding: Tips 81-90

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Original story posted on: September 30, 2013

ICD-10-PCS represents a major departure from ICD-9-CM procedure coding, and as such, many coding specialists find ICD-10-PCS much more challenging to learn than ICD-10-CM (which still shares many similarities with ICD-9-CM). In order to ease the transition from one code set to the other, we are providing tips for coding under this system.

 

To download the newly released 2014 ICD-10-PCS root operation tables and resources, go online to http://www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-PCS.html.

Tip No. 81

Educate physicians about the importance of documenting each anatomical site that is repaired when a patient suffers a first-degree perineal laceration during delivery. Code each body part that is repaired, which may include one or more of the following body parts:

  • Fourchette
  • Labia
  • Perineum skin
  • Vagina
  • Vulva
  • Slight perineal laceration, rupture, or tear

Example 1: ICD-10-PCS root operation table 0HQ would be used to report the repair of the perineum skin. Below is an excerpt from table 0HQ.

Section

0

Medical and surgical

Body System

H

Skin and breast

Operation

Q

Repair: Restoring, to the extent possible, a body part to its normal anatomic structure and function.

Body Part

Approach

Device

Qualifier

 

0 Skin, Scalp

1 Skin, Face

2 Skin, Right Ear

3 Skin, Left Ear

4 Skin, Neck

5 Skin, Chest

6 Skin, Back

7 Skin, Abdomen

8 Skin, Buttock

9 Skin, Perineum

A Skin, Genitalia

B Skin, Right Upper Arm

C Skin, Left Upper Arm

D Skin, Right Lower Arm

E Skin, Left Lower Arm

F Skin, Right Hand

G Skin, Left Hand

H Skin, Right Upper Leg

J Skin, Left Upper Leg

K Skin, Right Lower Leg

L Skin, Left Lower Leg

M Skin, Right Foot

N Skin, Left Foot

Q Finger Nail

R Toe Nail

 

0 Open

3 Percutaneous

4 Percutaneous Endoscopic

7 Via Natural or Artificial Opening

8 Via Natural or Artificial Opening Endoscopic

X External

 

 

 

Z No Device

 

 

 

Z No Qualifier

 

 


 

Example 2: ICD-10-PCS root operation table 0UQ would be used to report the repair of the fourchette (coded to vulva), labia (coded to vulva), vagina, or vulva. Below is an excerpt from table 0UQ.

Section

0

Medical and Surgical

Body System

U

Female Reproductive System

Operation

Q

Repair: Restoring, to the extent possible, a body part to its normal anatomic structure and function.

Body Part

Approach

Device

Qualifier

 

G Vagina

K Hymen

 

 

 

0 Open

3 Percutaneous

4 Percutaneous Endoscopic

7 Via Natural or Artificial Opening

8 Via Natural or Artificial Opening Endoscopic

X External

 

 

Z No Device

 

 

 

Z No Qualifier

 

 

J Clitoris

L Vestibular Gland

M Vulva

 

 

0 Open

X External

 

 

Z No Device

 

 

Z No Qualifier

Example 3: ICD-10-PCS root operation table 0WQ would be used to report the “slight repair of the perineum.” Below is an excerpt from table 0WQ.

Section

0

Medical and Surgical

Body System

W

Anatomical Regions, General

Operation

Q

Repair: Restoring, to the extent possible, a body part to its normal anatomic structure and function.

Body Part

Approach

Device

Qualifier

 

0 Head

2 Face

4 Upper Jaw

5 Lower Jaw

8 Chest Wall

K Upper Back

L Lower Back

M Perineum, Male

N Perineum, Female

 

0 Open

3 Percutaneous

4 Percutaneous Endoscopic

X External

 

 

 

Z No Device

 

 

 

Z No Qualifier

 

 


Tip No. 82

Educate physicians about the importance of documenting each anatomical site that is repaired when a patient suffers a second-degree perineal laceration during delivery. Code each body part that is repaired, which may include one or more of the following body parts:

  • Pelvic floor (each muscle, ligament or other tissue that is torn must be documented)
  • Perineal muscles
  • Vaginal muscles
  • Fourchette
  • Labia
  • Perineum skin
  • Vagina
  • Vulva
  • Slight perineal laceration, rupture, or tear

The “pelvic floor” refers to the pelvic diaphragm, the sphincter mechanism of the lower urinary tract, the upper and lower vaginal supports, and the internal and external anal sphincters. It is a network of muscles, ligaments, and other tissues that hold up the pelvic organs (vagina, rectum, uterus, and bladder). When this system is torn or weakens, the organs may shift, bulge, and push outward or against each other.

Example: ICD-10-PCS root operation table 0KQ would be used to report repair of a perineal muscle. Below is an excerpt from table 0KQ.

Section

0

Medical and Surgical

Body System

K

Muscles

Operation

Q

Repair: Restoring, to the extent possible, a body part to its normal anatomic structure and function.

Body Part

Approach

Device

Qualifier

 

0 Head Muscle

1 Facial Muscle

2 Neck Muscle, Right

3 Neck Muscle, Left

4 Tongue, Palate, Pharynx Muscle

5 Shoulder Muscle, Right

6 Shoulder Muscle, Left

7 Upper Arm Muscle, Right

8 Upper Arm Muscle, Left

9 Lower Arm and Wrist Muscle, Right

B Lower Arm and Wrist Muscle, Left

C Hand Muscle, Right

D Hand Muscle, Left

F Trunk Muscle, Right

G Trunk Muscle, Left

H Thorax Muscle, Right

J Thorax Muscle, Left

K Abdomen Muscle, Right

L Abdomen Muscle, Left

M Perineum Muscle

N Hip Muscle, Right

P Hip Muscle, Left

Q Upper Leg Muscle, Right

R Upper Leg Muscle, Left

S Lower Leg Muscle, Right

T Lower Leg Muscle, Left

V Foot Muscle, Right

W Foot Muscle, Left

 

 

 

 

 

 

 

 

 

 

 

 

 

 

0 Open

3 Percutaneous

4 Percutaneous Endoscopic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Z No Device

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Z No Qualifier

 

 


 

Tip No. 83

Educate physicians about the importance of documenting each anatomical site that is repaired when a patient suffers a third-degree perineal laceration during delivery. Code each body part that is repaired, which may include one or more of the following body parts:

  • Anal sphincter
  • Rectovaginal septum
  • Pelvic floor (each muscle, ligament or other tissue that is torn must be documented)
  • Perineal muscles
  • Vaginal muscles

Example: ICD-10-PCS root operation table 0DQ would be used to report repair of the anal sphincter. Below is an excerpt from table 0DQ.

Section

0

Medical and Surgical

Body System

D

Gastrointestinal System

Operation

Q

Repair: Restoring, to the extent possible, a body part to its normal anatomic structure and function.

Body Part

Approach

Device

Qualifier

 

R Anal Sphincter

S Greater Omentum

T Lesser Omentum

V Mesentery

W Peritoneum

 

 

0 Open

3 Percutaneous

4 Percutaneous Endoscopic

 

 

 

Z No Device

 

 

 

Z No Qualifier

 

Tip No. 84

Educate physicians about the importance of documenting each anatomical site that is repaired when a patient suffers a fourth-degree perineal laceration during delivery. Code each body part that is repaired, which may include one or more of the following body parts:

  • Anal mucosa
  • Rectal mucosa
  • Anal sphincter
  • Rectovaginal septum

 

Tip No. 85

A Muro-Kerr Cesarean section is a low cervical Cesarean section, and it should be coded as 10D00Z1. Below is an excerpt from table 10D.

Section

1

Obstetrics

Body System

0

Pregnancy

Operation

D

Extraction: Pulling or stripping out or off all or a portion of a body part by the use of force

Body Part

Approach

Device

Qualifier

 

0 Product of Conception

 

 

 

0 Open

 

 

Z No Device

 

 

0 Classical

1 Low Cervical

2 Extraperitoneal

Tip No. 86

Do not use the Resection root operation if a physician states that he or she resected an organ, but some portion of the organ is still remaining for an end-to-end anastomosis; the Excision root operation should be used instead.

For example, if a physician states that he or she performed an open “sigmoid resection with end-to-end anastomosis,” and the ends of the remaining sigmoid colon are brought together during the end-to-end anastomosis, then the entire sigmoid colon was not resected, based on the definition of “resection” in ICD-10-PCS. In this example, code 0DBN0ZZ would be assigned for the open sigmoid resection with end-to-end anastomosis.

Section

0

Medical and surgical

Body System

D

Gastrointestinal system

Operation

B

Excision: Cutting out or off, without replacement, a portion of a body part

Body Part

Approach

Device

Qualifier

 

1 Esophagus, Upper

2 Esophagus, Middle

3 Esophagus, Lower

4 Esophagogastric Junction

5 Esophagus

7 Stomach, Pylorus

8 Small Intestine

9 Duodenum

A Jejunum

B Ileum

C Ileocecal Valve

E Large Intestine

F Large Intestine, Right

G Large Intestine, Left

H Cecum

J Appendix

K Ascending Colon

L Transverse Colon

M Descending Colon

N Sigmoid Colon

P Rectum

 

 

 

 

 

 

 

 

 

0 Open

3 Percutaneous

4 Percutaneous Endoscopic

7 Via Natural or Artificial Opening

8 Via Natural or Artificial Opening Endoscopic

 

 

 

 

 

 

 

 

 

 

Z No Device

 

 

 

 

 

 

 

 

 

 

X Diagnostic

Z No Qualifier

 

 


 

Tip No. 87

There is no way to code an omental flap in the Transfer root operation of ICD-10-PCS. The omentum is a fold of the peritoneum that connects the stomach and the abdominal viscera, forming a protective and supportive construct. An omental flap is a segment of omentum, with its supplying blood vessels, transplanted either with an intact pedicle or as a free tissue to a distant area and re-vascularized by arterial and venous anastomoses.

Consider using the Repair root operation to classify the transplantation of an omental flap to a specific body part.

Tip No. 88

Educate physicians to specifically qualify each occurrence of a serosal tear as being incidental or a complication. The serosa is a serous membrane, especially one that lines the pericardial, pleural, and peritoneal cavities, enclosing their contents. If a repair performed on a serosal tear is documented as a complication, then the appropriate ICD-10-PCS code should be assigned. The repair of an incidental serosal tear is not coded.

In the American Hospital Association’s Second Quarter 2007 Coding Clinic for ICD-9-CM, the official guideline states that coders should query the provider as to whether a serosal tear was an incidental occurrence inherent in the surgical procedure, or whether the serosal tear was considered by the physician to be a complication of the surgical procedure.

Tip No. 89

A rectopexy procedure should be coded based on the objective of the procedure performed, because there are two references/options provided in the ICD-10-PCS Index:

Rectopexy

see Repair, Gastrointestinal System, 0DQ

see Reposition, Gastrointestinal System, 0DS

Tip No. 90

The antrum in the gastrointestinal tract is coded to the Stomach, Pylorus body part. Per the ICD-10-PCS Body Part Key:

Use “Stomach, Pylorus” for:

Pyloric antrum

Pyloric canal

Pyloric sphincter.


 

Below is an excerpt from the 0DB root operation table.

Section

0

Medical and surgical

Body System

D

Gastrointestinal system

Operation

B

Excision: Cutting out or off, without replacement, a portion of a body part

Body Part

Approach

Device

Qualifier

1 Esophagus, Upper

2 Esophagus, Middle

3 Esophagus, Lower

4 Esophagogastric Junction

5 Esophagus

7 Stomach, Pylorus

8 Small Intestine

9 Duodenum

A Jejunum

B Ileum

C Ileocecal Valve

E Large Intestine

F Large Intestine, Right

G Large Intestine, Left

H Cecum

J Appendix

K Ascending Colon

L Transverse Colon

M Descending Colon

N Sigmoid Colon

P Rectum

 

 

 

 

 

 

 

 

 

0 Open

3 Percutaneous

4 Percutaneous Endoscopic

7 Via Natural or Artificial Opening

8 Via Natural or Artificial Opening Endoscopic

 

 

 

 

 

 

 

 

 

 

Z No Device

 

 

 

 

 

 

 

 

 

 

X Diagnostic

Z No Qualifier

 

 

 

Read all previous coding tips

Read Coding Tips 91-100

Read Coding Tips 81-90

Read Coding Tips 71-80

Read Coding Tips 61-70

Read Coding Tips 51-60

Read Coding Tips 41-50

Read Coding Tips 31-40

Read Coding Tips 21-30

Read Coding Tips 11-20

Read Coding Tips 1-10

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Lolita M. Jones, RHIA, CCS

Lolita M. Jones, RHIA, CCS, is the principal of Lolita M. Jones Consulting Services (LMJCS), founded in October 1998 in Fort Washington, MD. Ms. Jones has over 25 years of experience in coding and consulting. She started preparing for the implementation of ICD-10-CM/PCS by going back to school. On September 12, 2010, Ms. Jones became an AHIMA-approved ICD-10-CM/PCS trainer.