Updated on: March 16, 2016

One Hundred Tips for ICD-10 Coding: Tips 21 - 30

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Original story posted on: March 15, 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 2013 ICD-10-PCS root operation tables and resources, go online to http://www.cms.gov/Medicare/Coding/ICD10/2013-ICD-10-PCS-GEMs.html.

Tip No. 21

In some Eye root operation tables (such as 085), be careful when coding a retinal vessel (a retinal artery or vein), because the vessel is listed separately and is not included in the Retina body part.

Section

0

Medical and surgical

Body System

8

Eye

Operation

5

Destruction: Physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent

Body Part

Approach

Device

Qualifier

 

 

2 Anterior Chamber, Right

3 Anterior Chamber, Left

4 Vitreous, Right

5 Vitreous, Left

C Iris, Right

D Iris, Left

E Retina, Right

F Retina, Left

G Retinal Vessel, Right

H Retinal Vessel, Left

J Lens, Right

K Lens, Left

 

 

 

 

 

 

3 Percutaneous

 

 

 

 

 

 

 

Z No Device

 

 

 

 

 

Z No Qualifier

 

 

 

 


 

Tip No. 22

When coding from the Ear, Nose, Sinus root operation tables (such as 095), do not select the Accessory Sinus body part if the specific paranasal sinus is listed:

Section

0

Medical and surgical

Body System

9

Ear, Nose, Sinus

Operation

5

Destruction: Physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent

 

Body Part

Approach

Device

Qualifier

 

 

B Mastoid Sinus, Right

C Mastoid Sinus, Left

M Nasal Septum

P Accessory Sinus

Q Maxillary Sinus, Right

R Maxillary Sinus, Left

S Frontal Sinus, Right

T Frontal Sinus, Left

U Ethmoid Sinus, Right

V Ethmoid Sinus, Left

W Sphenoid Sinus, Right

X Sphenoid Sinus, Left

 

 

 

 

 

0 Open

 

3 Percutaneous

 

4 Percutaneous

Endoscopic

 

 

 

 

 

 

 

Z No Device

 

 

 

 

 

Z No Qualifier

 

 

 

 


 

Tip No. 23

When coding an endotracheal tube (cuffed or double-lumen) procedure in a Respiratory System root operation table (such as 0B2), select the device value that states “intraluminal device, endotracheal airway.”

Tip No. 24

The Minor Salivary Gland body part is listed in some of the Mouth and Throat root operation tables (such as 0C5). The anterior lingual gland is the only minor salivary gland referenced in the ICD-10-PCS Body Part Key, however, and there are numerous minor oral salivary glands located in the buccal, labial, and palatal mucosa. It is incorrect to operate under the thinking that the anterior lingual gland is the only minor salivary gland.

Tip No. 25

Some of the Mouth and Throat root operation tables (such as 0C5) reference the Upper Tooth body part, but the specific upper teeth are not listed.

For a diagram of all permanent upper teeth, go online to http://www.americantooth.com/downloads/instructions/Dental_Sys_Permanent_Teeth.pdf.

For a diagram of all primary upper teeth, go to http://www.americantooth.com/downloads/instructions/Dental_Sys_Primary_Teeth.pdf.

Tip No. 26

Some of the Mouth and Throat root operation tables (such as 0C5) reference the Lower Tooth body part, but the specific lower teeth are not listed.

For a diagram of all permanent lower teeth, go online to http://www.americantooth.com/downloads/instructions/Dental_Sys_Permanent_Teeth.pdf.

For a diagram of all primary lower teeth, go to http://www.americantooth.com/downloads/instructions/Dental_Sys_Primary_Teeth.pdf.

Tip No. 27

When gingival (gum) surgery is performed, please note the specific location of the procedure(s), because the Upper Gingiva and Lower Gingiva body parts are listed in some of the Mouth and Throat root operation tables (such as 0CQ).

Tip No. 28

Some ICD-10-PCS root operation tables (such as 0J0) contain the Subcutaneous Tissue and Fascia body parts. Although not listed in ICD-10-PCS, the terms “hypodermis” and “subcutis” also are used by clinicians to describe the subcutaneous tissue.

Title: Anatomy: Skin: Epidermis, Dermis and Subcutaneous Tissue
Source: National Cancer Institute
AV Number: AV-0000-4287
Reuse Restrictions: None - This image is in the public domain and can be freely reused.

 


 

Tip No. 29

When subcutaneous or fascia surgery is performed on the neck, please note the specific location of the procedure, because the Anterior Neck and Posterior Neck body parts are listed in some of the Subcutaneous Tissue and Fascia root operation tables (such as 0J0).

Tip No. 30

The 2013 ICD-10-PCS Index does not reference a breast implant capsulotomy or capsulectomy procedure.

According to the Food and Drug Administration (FDA), breast implant capsular contracture is a tightening of the tissue capsule around an implant, resulting in firmness or hardening of the breast and squeezing of the implant, if severe.

During a capsulotomy, the breast implant capsule (scar tissue) is released through an incision into the capsule. Until an official ICD-10-PCS coding guideline is published, consider using the Skin and Breast root operation table 0HN to classify a breast implant capsulotomy. Table 0HN classifies Release, or freeing a body part from an abnormal physical constraint by cutting or by the use of force.

During a capsulectomy, the breast implant capsule (scar tissue) is removed. Until an official ICD-10-PCS coding guideline is published, consider using the Skin and Breast root operation table 0HC to classify a breast implant capsulectomy. Table 0HC classifies Extirpation, or taking or cutting out solid matter from a body part.

 

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

NOTES

Food and Drug Administration, Risk of Breast Implants, http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/Breastimplants/ucm064106.htm

Geerling GRaus PMurube J. Minor salivary gland transplantation. Dev Ophthalmol. 2008;41:243-54. doi: 10.1159/000131093.

Justi Educational Department, Dental Numbering Systems: Permanent Teeth, September 2003, http://www.americantooth.com/downloads/instructions/Dental_Sys_Permanent_Teeth.pdf

Justi Educational Department, Dental Numbering Systems: Primary (Deciduous) Teeth, September 2003, http://www.americantooth.com/downloads/instructions/Dental_Sys_Primary_Teeth.pdf

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.