KKRINGLE HIM1103-Mod-04-Lab-Worksheet (2) 0903
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Module 04 Lab Activity – ICD-10-PCS Coding
Overview:
There are 3 parts to this assignment. In parts 1 and 2, you will need to complete the table below. In part 3 you will use the Clintegrity encoder
software and provide screenshots that show your work.
Part 1: Coding using the Alphabetical Index
Instructions:
In the table below, read each Procedural Statement (in column 1), enter the correct Root Operation (in column 2) and the first three characters of the ICD-10 PCS Code from the Alphabetic Index (in column 3).
Steps for Identifying the Root Operation and the First 3 Characters of the PCS Code using the Alphabetic Index
For each Procedural Statement,
1.
Identify the Root Operation or Main Term and the Body Part from the procedural statement. (See “Main Term” in the Introduction to the ICD-10-PCS code book).
2.
Go to the Alphabetic Index to locate the Root Operation or Main Term you identified. The Alphabetic Index is found in the front of the ICD-10-PCS code book. Follow any “See” references to properly identify the root operation.
3.
Apply the appropriate coding guidelines and definitions to your decision-making process to determine the official PCS Root Operation.
4.
Next, locate the body part identified in #1 under the Root Operation chosen.
5.
Compare the details in the Alphabetical Index to the details in the Procedural Statement. Ensure that it is the best match.
6.
Enter the official PCS Root Operation in Column 2 of the worksheet
7.
Enter only the first three
characters
of the PCS code found in the Alphabetic Index for the Root Operation and Body Part in Column 3 of the worksheet.
8.
Do not proceed to the Code Tables for this part.
Part 2: Coding Pathways using the Code Tables
Instructions:
Use the first three characters you identified in column 3 to finish the construction of the appropriate ICD-10-PCS Code from the Code Tables and enter it into column 4.
Steps for Constructing the PCS Code using the Code Tables
For each Procedural Statement,
1.
Use the three character values for the Section, Body System and Root Operation from column 3 and find that category in the Code Table.
2.
Apply all relative coding guidelines and definitions to determine the remaining 4 characters from the Code Table e.g. Body Part, Approach, Device and Qualifier.
3.
Be aware of multiple rows for Body Part values with different combinations of Approach, Device and/or Qualifier values.
4.
Follow the same row for selection of the 4
th
– 7
th
character values.
Page 1
of 4
5.
Compare the final seven-character code to the procedural statement to ensure you have reached the final code that best matches the Procedural Statement; if you have not, return to step 2.
Table for Parts 1 and 2
Column 1
Column 2
Column 3
Column 4
Procedural Statement
Root Operation ICD-10-PCS 1
st
Three Characters from the Alphabetic Index
ICD-10-PCS Code from
Code Tables
Example: Laparoscopic appendectomy to remove the appendix
Resection
0DT
0DTJ4ZZ
1. Amputation of the left index finger, distal end
Amputation
0X6
0X6P0Z0
2. Partial gastrectomy of the stomach via an open approach for frozen section biopsy
Resection
0DT
0DT60ZZ
3. Diagnostic evaluation of the upper intestinal tract via endoscopic approach per mouth. No abnormal findings.
Inspection
0DJ
0DJ08ZZ
4. Cholecystectomy of the entire gallbladder, open approach
Resection
0FT
0FT40ZZ
5. Open reduction and internal fixation of displaced fracture of
the left tibia
Reduction
0QS
0QSH04Z
6. Total left knee replacement, open approach, using a synthetic substitute and cement
Replacement
0QR
OQRF0JZ
7. Laparoscopic removal of a calculus from the right ureter without incision
Extraction
0TD
0TD70ZZ
8. Complete closure of the bilateral fallopian tubes with extraluminal device; via percutaneous laparoscopic approach
Occlusion
0UL
0UL70CZ
9. Percutaneous iliac bone marrow biopsy; diagnostic
Extraction
07D
07DR3ZX
10. Removal of ascites fluid for diagnostic purposes from the abdomen; via small incision
Drainage
0W9
0W9G3ZX
Page 2
of 4
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