I-10-PCS: The Endocrine System

on Monday, 07 April 2014. All News Items | Documentation | Coding

For this edition of the I-10 Corner, we have included some helpful hints that will make coding procedures in the Endocrine System a little easier.   To gain familiarity, practice looking up procedures in the ICD-10-PCS coding book that are performed at your facility on a routine basis.

Knowing the Root Operations is the key to making all of this work!                                              

FROM THE ICD-10-PCS REFERENCE MANUAL

Examples of Root Operations

Excision—Root operation B

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

Explanation: The qualifier Diagnostic is used to identify excision procedures that are biopsies

Examples: Partial thyroidectomy, ovarian biopsy

Excision is coded when a portion of a body part is cut out or off using a sharp instrument. All root operations that employ cutting to accomplish the objective allow the use of any sharp instrument, including but not limited to

    • Scalpel
    • Wire
    • Scissors
    • Bone saw
    • Electrocautery tip

Resection—Root operation T

Definition: Cutting out or off, without replacement, all of a body part

Explanation: N/A

Examples: Total nephrectomy, total lobectomy of lung

Resection is similar to Excision, except Resection includes all of a body part, or any subdivision of a body part that has its own body part value in ICD-10-PCS, while Excision includes only a portion of a body part.

Release—Root operation N

Definition: Freeing a body part from an abnormal physical constraint by cutting or by use of force

Explanation: Some of the restraining tissue may be taken out but none of the body part is taken out

Examples: Adhesiolysis of right ovary

The objective of procedures represented in the root operation Release is to free a body part from abnormal constraint. Release procedures are coded to the body part being freed. The procedure can be performed on the area around a body part, on the attachments to a body part, or between subdivisions of a body part that are causing the abnormal constraint.

Reposition—Root operation S

Definition: Moving to its normal location or other suitable location all or a portion of a body part

Explanation: The body part is moved to a new location from an abnormal location, or from a normal location where it is not functioning correctly. The body part may or may not be cut out or off to be moved to the new location

Examples: Reposition of undescended testicle

Reposition represents procedures for moving a body part to a new location. The range of Reposition procedures includes moving a body part to its normal location, or moving a body part to a new location to enhance its ability to function.

Laterality is necessary in code assignment for the following organs:

  • Thyroid
  • Ovaries
  • Testicles
  • Adrenals
EXAMPLE

Procedure

I-9

I-10

Difference

Thyroidectomy, Complete 06.4 0GTG0ZZ (L)
and
0GTH0ZZ (R)
Both I-10 codes must be assigned.
(See guideline B4.3 below)
       
Thyroid Biopsy 06.11 0GBG3ZZ (L)
or
0GBH3ZZ (R)
Must know which lobe is being biopsied.

 

Don’t Forget: 0 vs O:

FROM THE ICD-10-PCS REFERENCE MANUAL

Values

One of 34 possible values can be assigned to each character in a code: the numbers 0 through 9 and the [whole] alphabet (except I and O, because they are easily confused with the numbers 1 and 0).

 

FROM THE ICD-10-CM OFFICIAL GUIDELINES FOR CODING AND REPORTING 2014

B4. Body Part

B4.3 Bilateral body part values are available for a limited number of body parts. If the identical procedure is performed on contralateral body parts, and a bilateral body part value exists for that body part, a single procedure is coded using the bilateral body part value. If no bilateral body part value exists, each procedure is coded separately using the appropriate body part value.

 

Article by Anita Meyers

Anita Meyers, RHIT, CCS, AHIMA-approved ICD-10 Trainer is an Inpatient Coding Professional at Medical Management Plus. Anita has over twenty-eight years of experience in inpatient and outpatient coding including 17 years of work at AQAF reviewing inpatient and outpatient records from Alabama hospitals. In addition to reviewing records she was the team leader in Beneficiary Services where she participated in case review activities, received and processed beneficiary complaints and handled fee-for-service denials for home health, hospice and skilled nursing facility services. Prior to joining the MMP team, Anita left AQAF to become an inpatient contract coder and worked at various hospitals in central Alabama. In her current position, Anita is an integral part of the Inpatient Services at Medical Management Plus. You may contact Anita at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

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