Code Building Exercises ICD 10 PCS CODING

Code Building Exercises ICD 10 PCS CODING Instructions: Answer the questions following each of the cases. Exercise 1: DIAGNOSIS: Subdural hematoma, left hemisphere OPERATION PERFORMED: 1. Evacuation of subdural hematoma 2. Implantation of a subdural externalized shunt DESCRIPTION OF OPERATION: The patient was brought to the operating room in the supine position after induction of general endotracheal anesthesia. The head was placed in a gel donut on a horseshoe. Frontal areas were shaved, prepped and draped in standard sterile fashion using a Loban drape. A long line of incision was marked bilaterally in the frontal region and infiltrated with 1/2 percent lidocaine with 1:200,000 epinephrine. The skin incision was made in the frontal region down to the pericranium. Subperiosteal dissection was carried out. A burr hole was created and a craniectomy was extended. The dura was opened and the dural leaflets were obtained. Subdural space was copiously irrigated with normal saline until the egress was clear. A 35-cm ventriculostomy catheter was brought into the field and inserted into the subdural space without difficulty. This was now brought out through the original burr hole, tunneled under the skin and brought out of the skin through a separate incision. This was then secured to the skin and connected to an externalized drainage bag. Attention was directed to reconstruction of the cranial opening. The reconstruction was carried out using the Lorenz plating system and titanium microscrews for cranioplasty. The wound was irrigated and closed in the usual fashion using 2-0 Vicryl for the deeper layers and staples for the skin. Sterile dressings were applied. Questions: 1.1. Which root operation is assigned for the evacuation of the subdural hematoma? 1.2. Is a separate code assigned for the externalized shunt? 1.3. Is a separate code assigned for the craniectomy? 1.4. A Lorenz plating system and titanium microscrews are used to perform a cranioplasty. Is a code for the insertion of an internal fixation device into the skull assigned for this case? 1.5. What PCS code(s) should be assigned? Exercise 2: PRE- AND POSTOPERATIVE DIAGNOSIS: Anterior mediastinal mass PROCEDURE: Median sternotomy and extirpation of mass FINDINGS: The mass was left of the pulmonary artery and was filled with thick, milky fluid with calcifications. PROCEDURE: The patient was fully anesthetized, and the chest was prepped and draped. A midline sternotomy was made and the anterior dissection was begun by reflecting the thymic fat pad off the pericardium. The right thyrothymic tract was completely freed. Blunt dissection continued to the left until the tumor was fully mobi- lized and excised. The tumor was removed from the operative field for permanent pathology. Hemostasis was achieved and the sternotomy was closed. Questions: 2.1. Did the surgeon use the term “extirpation” according to the ICD-10-PCS definition? Why or why not? 2.2. What root operation should be assigned? 2.3. What PCS code(s) should be assigned? Exercise 3: PREOPERATIVE DIAGNOSIS: Dyspnea POSTOPERATIVE DIAGNOSIS: Mucus plug in right upper lobe bronchus PROCEDURE: Bronchoscopy INDICATION: Rule out inhaled foreign body and pneumonia PROCEDURE DESCRIPTION: The flexible bronchoscope was passed through the oral cavity. A very large mucus plug was noted in the right upper lobe bronchus and this was cleared with a balloon using pullback. The tra- cheobronchial tree was examined and no other obstructions or foreign bodies were found. Questions: 3.1. Is the mucus plug part of the patient’s body part or is it an abnormal by-product of a bodily function? 3.2. Which group of root operations should be used to select the root operation for coding? 3.3. Which root operation is assigned? 3.4. What PCS code(s) should be assigned? Operative Report 4. PREOPERATIVE DIAGNOSIS: Ruptured spleen with hemoperitoneum and secondary peritonitis POSTOPERATIVE DIAGNOSIS: Ruptured spleen with hemoperitoneum and secondary peritonitis PROCEDURES PERFORMED: 1. Exploratory laparotomy 2. Splenectomy 3. Evacuation of hemoperitoneum 4. Placement of drain in the left upper quadrant INDICATION FOR PROCEDURE: The patient fell almost two days ago and experienced increasing left upper abdominal pain. The patient became disoriented and fell again about three hours ago, necessitating immediate transfer to the hospital. An apparent subcapsular hematoma of the spleen was suffered during the first fall and was ruptured during the fall earlier today. PROCEDURE: The patient was taken emergently to the operating room. After successful induction of general anesthesia, the abdomen was prepped and draped using the normal sterile technique. The abdomen was opened through a vertical midline incision. The patient had massive hemoperitoneum with about 1000 ccs of liquid, clot, and blood in the abdomen, and about 500 ccs of solid clot in the left upper quadrant that appeared to be over 24 hours old. The spleen was completely dissected from its capsule by the hematoma. There was erythema of the peritoneum in the left upper quadrant consistent with localized peritonitis due to the hematoma and hemoperito- neum. The abdomen was carefully inspected and all solid matter and clots were removed. There was bleeding from the helium of the spleen. It was clamped with large Peon clamps and the splenic pedicle was divided with scissors. The vessels were ligated with #2 Vicryl ligatures, and the spleen was removed. There was good hemostasis. There were bits of splenic tissue all over the abdomen, which were removed as thoroughly as possible. The abdomen was then copiously irrigated. All other abdominal structures were intact. The left upper quadrant was then drained with a #19 French round Blake drain and the abdomen was closed with #1 PDS and #2 Vicryl, and the skin was closed with staples. The patient was sent to the intensive care unit in stable condition. 4.1 What is the PCS Code for this case? Case 5: Operative Report PREOPERATIVE DIAGNOSIS: Left orbital pseudotumor POSTOPERATIVE DIAGNOSIS: Left orbital pseudotumor OPERATION: Anterior orbitotomy with a biopsy of lacrimal gland, left orbit SURGICAL INDICATIONS: The patient is a 10-year-old boy with a two-year history of chronic inflammation of the left orbit, including swelling of the medial and lateral recti muscles and the ipsilateral lacrimal gland, and Tenon’s capsule. Previous diagnostic studies included a normal CBC, C-reactive protein (less than 0.1), and C-ANCA and P-ANCA, which were negative, suggesting there was no underlying vasculitis. Because of con- tinued chronic inflammation for which he will probably need oral steroids, pretreatment biopsy of involved tissue was recommended. Brief review of the CT scan revealed that there was considerable enlargement of the lacrimal gland in the left orbit, therefore biopsy of this tissue was recommended. SURGICAL PROCEDURE: The child was brought to the operating room after adequate preoperative medications. He was induced with face mask anesthesia, at which time an intravenous line was inserted; cardiac monitor, blood pressure cuff, EKG leads, and pulse oximeter were attached. The child was then intubated and maintained with an appropriate combination and mixture of anesthetic gases and oxygen compatible with general surgery. His face was prepared and draped in the usual sterile fashion. Inspection of the left eyelid revealed that there was no crease. There was proptosis of the ipsilateral globe with fullness of the left upper eyelid. There seemed to be a previous scar in the left upper eyelid. Therefore, the decision was made to position the anterior orbitotomy on the previous left upper eyelid scar. Therefore, approx- imately a 2 cm area was demarcated with a marking pen in the superotemporal aspect of the upper eyelid above the area where the eyelid crease would normally be. The subcutaneous tissue was infiltrated with 1 percent Xylocaine with epinephrine. A #67 Beaver blade was used to incise the eyelid skin and superficial orbicularis. Prior to doing this, the eyelid was put on stretch by putting a 6-0 silk through the lash line and pulling the upper eyelid taut. Then the eyelid skin was tented up with small muscle hooks. The orbicularis muscle was incised centrally, and then the incision in the orbicularis was extended to the medial and lateral margins of the skin inci- sion. Hemostasis was obtained with bipolar cautery. The sharp dissection was continued posteriorly to the level 5.1 What is the PCS Code for this case?

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