Updates
ICD-10-CM and ICD-10-PCS Preview Exercises
AHIMA Product AC216009
Changes to reflect code updates as of January 2011
Note: Any question or solution that has been updated appears in this list, and this
version of the question or solution should be substituted in full for the original question
or solution published in the book. To help readers see what changes that have been
made, any text that has been added or changed appears in red. In most cases, text that
has been deleted is not shown; however, in some instances, for clarity, deleted text is
also shown in strikethrough font.
Updates are presented in the same sections as appear in the text:
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Part 1: ICD-9-CM to ICD-10-CM and ICD-10-PCS Transitional Exercises
Part 1: Solutions to ICD-9-CM to ICD-10-CM and ICD-10-PCS Transitional
Exercises
Part 2: Basic ICD-9-CM to ICD-10-CM and ICD-10-PCS Coding Exercises
Part 2: Solutions to Basic ICD-9-CM to ICD-10-CM and ICD-10-PCS Coding
Exercises
Updates to Part 1 Questions: ICD‐9‐CM to ICD‐10‐CM and ICD‐10‐PCS Transitional Exercises 13. Laceration of the left index finger with a knife while slicing meat at work in a restaurant.
The patient was in the process of preparation of the meat for cooking.
ICD-9-CM: __________________________________________________________
ICD-10-CM: _________________________________________________________
18. Postoperative pulmonary artery embolism, initial encounter
ICD-9-CM: _____________________________________________________________
ICD-10-CM: ____________________________________________________________
40. Crush syndrome with hemorrhaging; lacerations of small and large intestines. Ten-year-old
patient was rough housing with his brother in the shop and a sheet of drywall accidentally fell
on the patient. The patient was immediately sent to the operating room where an open repair
of the lacerations of the small and large intestines due to the crushing injury was performed
(code both diagnosis and procedure codes)
ICD-9-CM: _________________________________________________________________
_____________________________________________________________________________
ICD-10-CM: _____________________________________________________________
_____________________________________________________________________________
ICD-10-PCS: ______________________________________________________________
Updates to Part 1 Solutions: Solutions to ICD‐9‐CM to ICD‐10‐CM and ICD‐10‐PCS Transitional Exercises 1. Decubitus ulcer of the right side of the lower back, Stage III
ICD-9-CM
ICD-10-CM
Code(s) Assigned
L89.133 Pressure ulcer of right lower back, stage 3
707.03 Pressure ulcer of lower back
707.23 Pressure ulcer stage III
Alphabetic Index:
Ulcer
decubitus – (see also Ulcer, pressure)
Index and Tabular Volumes
Alphabetic Index:
Ulcer
decubitus – see Ulcer, pressure, by site
Ulcer
pressure
back
lower 707.03
stage III 707.23
Ulcer
pressure
back L89.1—
Tabular:
707.0 Pressure ulcer
Decubitus ulcer
Use additional code to identify pressure
ulcer stage (707.20–707.25)
707.03 Lower back
Tabular:
L89 Pressure ulcers
Includes: decubitus ulcers
L89.13 Pressure ulcer of right lower back
L89.133 Pressure ulcer of right lower
back, Stage 3
707.2 Pressure ulcer stages
Code first site of pressure ulcer
(707.00–707.09)
707.23 Pressure ulcer, stage III
Code Comparisons
 One code category for all chronic skin ulcers
 Three code categories for chronic skin ulcers:
(decubitus and non-decubitus)
L89 pressure ulcer
 Two codes required to completely code a
L97 non-pressure chronic ulcer of lower limb, NEC
pressure ulcer
L98.4xx non-pressure chronic ulcer of skin, NEC
 One code used to classify both the site, including
 One code to identify site
laterality of pressure ulcer, as well as the stage
 One code to identify stage
Documentation Needed
 Specification that the skin ulcer is a decubitus
 Specification that the skin ulcer is a decubitus
 Specific site of decubitus ulcer
 Specific site, including the specific region and left or
right side
 Depth of the ulcers (coders will need to be able to
recognize what depth is associated with specific  Depth of the ulcer (coders will need to be able to
stages of ulcers)
recognize what depth is associated with specific
stages of ulcers)
5. Appendectomy
Supporting documentation: The operative report indicates that the entire appendix was
removed via an open abdominal incision
ICD-9-CM
47.09 Other appendectomy
Alphabetic Index:
Appendectomy (with drainage) 47.09
incidental 47.19
laparoscopic 47.11
laparoscopic 47.11
ICD-10-PCS
Code(s) Assigned
0DTJ0ZZ
0 Medical and surgical section (procedure type)
D Gastrointestinal system (body system)
T Resection (root operation)
J Appendix (body part)
0 Open (approach)
Z None (device)
Z None (qualifier)
Index and Tabular Volumes
Alphabetic Index:
Appendectomy
– see Excision, Appendix 0DBJ
– see Resection, Appendix 0DTJ
Resection
Appendix 0DTJ
Tabular:
47.0 Appendectomy
47.01 Laparoscopic appendectomy
47.09 Other appendectomy
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Tabular (Tables):
Reference the table for 0DT (see the Excerpt from the
ICD-10-PCS Tables) to look up the remaining
characters of the code. In this case the specific body
part is appendix (J), the approach is open (0), and there
is no device or qualifier (Z).
Code Comparisons
Classification of appendectomy is laparoscopic
 Specificity as to whether appendectomy is partial
or other with no specific code for an open
or total
approach
 Code includes the operative approach
Classification of appendectomy does not
 There is no code for an incidental appendectomy
provide further specificity as to whether a partial  Resection is the correct root operation not excision
or total procedure was performed
o Resection: cutting out or off, without
Specifies if appendectomy is incidental or not
replacement, all of a body part
o Excision: cutting out or off, without
replacement, a portion of a body part
Documentation Needed
Whether the appendectomy was incidental
 The reason for the appendectomy (incidental or not)
is not a criteria for selection of the code
Whether it was performed laparoscopically
 The operative approach must be known (open
versus laparoscopic)
 The coding professional must be able to determine
whether the appendix was removed in part or in
total
Excerpt from the ICD-10-PCS Tables
0: Medical Surgical
D: Gastrointestinal system
T: Resection: Cutting out or off, without replacement, all of a body part
Body Part
Character 4
1 Esophagus, upper
2 Esophagus, middle
3 Esophagus, lower
4 Esophagogastric junction
5 Esophagus
6 Stomach
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
Q Anus
R Anal sphincter
S Greater omentum
T Lesser omentum
Approach
Character 5
0 Open
Device
Character 6
Qualifier
Character 7
Z None
Z None
Z None
Z None
4 Percutaneous Endoscopic
7 Via Natural or Artificial
Opening
8 Via Natural or Artificial
Opening Endoscopic
0 Open
4 Percutaneous Endoscopic
7. Arthroscopic partial meniscectomy, left knee
Supporting documentation: The operative report indicates the surgeon utilized an arthroscope to
perform a partial meniscectomy of the left knee
ICD-9-CM
ICD-10-PCS
Code(s) Assigned
80.6 Excision of semilunar cartilage of knee
0SBD4ZZ
0 Medical and surgical section (procedure type)
S Lower joints (body system)
B Excision (root operation)
D Knee joint, left (body part)
4 Percutaneous endoscopic (approach)
Z None (device)
Z None (qualifier)
Index and Tabular Volumes
Alphabetic Index:
Alphabetic Index:
Meniscectomy (knee) NEC 80.6
Meniscectomy
– see Excision, lower joints 0SB
– see Resection, lower joints OST
Excision
Joint
Knee
Left 0SBD
Tabular:
80.6 Excision of semilunar cartilage of knee
Excision of meniscus of knee
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Tabular (Tables):
Reference the table for 0SB (see the Excerpt from the
ICD-10-PCS Tables) to look up the remaining
characters of the code. In this case the specific body
part is the left knee joint (D), the approach is
arthroscopic (4), and there is no device or qualifier (Z).
Code Comparisons
Very little specificity, no way to indicate if the
 Many more characters, appropriate code is “built”
meniscectomy was complete or partial
rather than selected in the Tabular
The code does not indicate that the procedure  Specificity as to whether meniscectomy is partial or
was arthroscopic (application of a separate
total
code to denote this, 80.26, is inappropriate as  Code specifies laterality of joint
the surgical approach is not reported in ICD-9-  Code specifies the operative approach
CM)
Documentation Needed
 The operative approach must be known (open
Documentation of the procedure performed
versus arthroscopic)
 Whether the meniscus was removed in part or in
total
Excerpt from the ICD-10-PCS Tables
0: Medical Surgical
S: Lower Joints
B: Excision: Cutting out or off, without replacement, a portion of a body part
Body Part
Approach
Device
Character 4
Character 5
Character 6
0
2
3
4
5
6
7
8
9
B
C
D
F
G
H
J
K
L
M
Lumbar vertebral joint
Lumbar vertebral disc
Lumbosacral joint
Lumbosacral disc
Sacrococcygeal joint
Coccygeal joint
Sacroiliac joint, right
Sacroiliac joint, left
Hip joint, right
Hip joint, left
Knee joint, right
Knee joint, left
Ankle joint, right
Ankle joint, left
Tarsal joint, right
Tarsal joint, left
Metatarsal-tarsal joint, right
Metatarsal-tarsal joint, left
Metatarsal-phalangeal joint,
right
N Metatarsal-phalangeal joint,
left
P Toe phalangeal joint, right
Q Toe phalangea joint, left
0 Open
3 Percutaneous
4 Percutaneous Endoscopic
Z None
Qualifier
Character 7
X Diagnostic
Z None
11. Permanent tracheostomy, open approach
ICD-9-CM
ICD-10-PCS
Code(s) Assigned
31.29 Other permanent tracheostomy
0B110F4
0 Medical and surgical section (procedure type)
B Respiratory system (body system)
1 Bypass (root operation)
1 Trachea (body part)
0 Open (approach)
F Tracheostomy (device)
4 Cutaneous (qualifier)
Index and Tabular Volumes
Alphabetic Index:
Alphabetic Index:
Tracheostomy – see Bypass, Respiratory
Tracheostomy (emergency) (temporary) (for
assistance in breathing)
System 0B1
permanent NEC 31.29
Bypass
Trachea 0B11
Tabular (Tables):
Reference the table for 0B1 (see Excerpt from the
ICD-10-PCS Tables) to look up the
remaining characters of the code. In this case the
specific body part is the trachea (1), the approach is
open (0), the device is a tracheostomy device (F), and
the qualifier of cutaneous (4) applies.
Code Comparisons
Classifies the anticipated duration of the
 Distinguishes the opening of the trachea by the
tracheostomy use, temporary versus
surgical approach used
permanent and whether the intervention is
 Distinguishes the type of device remaining at the
revision of the tracheostomy
end of the procedure
Documentation Needed
Clarity is needed regarding whether the
 Documentation must specify the approach to
intervention is intended for short term or longaccurately assign the fifth character
term use
 Documentation must specify if a device was left
Documentation distinguishing the intervention
remaining at the end of the procedure and if so
as revising an existing tracheostomy or an
the type of device
initial placement
Tabular:
31.29 Other permanent tracheostomy
Code also any synchronous bronchoscopy
if performed (33.21–33.24, 33.27)
Excludes: that with laryngectomy (30.3–
30.4)
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Excerpt from the ICD-10-PCS Tables
0: Medical and Surgical
B: Respiratory System
1: Bypass: Altering the route of passage of the contents of a tubular body part
Body Part
Character 4
Approach
Character 5
Device
Character 6
Qualifier
Character 7
1 Trachea
0 Open
D Intraluminal device
6 Esophagus
1 Trachea
0 Open
3
F Tracheostomy device
Z No device
4 Cutaneous
1 Trachea
3 Percutaneous
4 Percutaneous
Endoscopic
F Tracheostomy device
Z No Device
4 Cutaneous
13. Laceration of the left index finger with a knife while slicing meat at work in a restaurant.
The patient was in the process of preparation of the meat for cooking.
ICD-9-CM
ICD-10-CM
Code(s) Assigned
883.0 Open wound of finger without mention of
S61.211A Laceration without foreign body of left
complication
index finger without damage to the nail, initial
E920.3 Accidents caused by knifes, swords, and
encounter
daggers
W26.0xxA Contact with knife, initial encounter
E849.6 Place of occurrence, public building
Y92.511 Restaurant or café as the place of
E015.0 Food preparation and clean up
occurrence of the external cause
E000.0 External cause status, civilian activity done
Y93.G1 Activity, food preparation and clean up
for income or pay
Y99.0 External Cause Status, civilian activity done
for income or pay
Index and Tabular Volumes
Alphabetic Index:
Alphabetic Index:
Laceration
Wound, open
finger(s)
finger(s) (nail) (subungual) 883.0
index
left S61.211
Index to External Causes:
Cut
by
knife E920.3
Accident
occurring (at) (in)
restaurant E849.6
Activity
food preparation and clean up E015.0
External cause status
for income E000.0
Index to External Causes:
Cut, cutting (any part of body) (accidental)
– see also Contact, with, by object or machine
Contact
with
knife W26.0
Place of Occurrence
restaurant Y92.511
Activity
Food preparation and clean up Y93.G1
External Cause Status
Civilian activity done for income or pay Y99.0
Tabular:
883.0 Open wound of finger(s) without mention of
complication
Tabular:
S61 Open wound of wrist, hands and finger(s)
The appropriate seventh character is to be
added to each code from category S61:
A initial encounter
D subsequent encounter
S sequela
S61.211 Laceration without foreign body of
left index finger without damage to
nail
E920.3 Accidents caused by knives, swords,
and daggers
E849.6 Place of occurrence, public building
Restaurant
E015.0 Food preparation and clean up
E000.0 External cause status, civilian activity
done for income or pay
W26 Contact with knife, sword or dagger
The appropriate seventh character is to be
added to each code from category W26:
A initial encounter
D subsequent counter
S sequela
W26.0 Contact with knife
Y92.511 Restaurant or café as the place of
occurrence of the external cause
Y93 Activity codes
Y93.G Activities involving food preparation,
cooking and grilling
Y93.G1 Activities involving food preparation
and clean up
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

Y99 External Cause Status
Y99.0 Civilian activity done for income or
pay
Code Comparisons
Anatomic location of the wound is nonspecific as
 Anatomic location of the laceration classifies
to which finger
specifically which finger (left index) was injured
Place of occurrence is much less specific
 The extension clarifies that this is the initial
encounter
Additional codes indicate not only where, but
also what the person was doing when injured
 Additional codes indicate not only where, but
also what the person was doing when injured
Documentation Needed
 The site of injury (finger)
 Whether or not there is delayed healing, delayed
treatment, foreign body, or infection of the
wound (denoted “complicated”)
 Where the accident occurred and what activity
the patient was doing when the injury occurred
 How the accident occurred
 Whether the injury was work related, military, or
a student
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


Specific anatomic site of the injury (laterality and
which finger)
The extent of the injury, whether or not the nail
was involved
Whether the encounter is the initial episode,
subsequent episode, or for sequela
Where the injury occurred and what activity the
patient was doing when the injury occurred
Whether the injury was work related, military, or
a student
15. Common bile duct exploration, open approach
ICD-9-CM
ICD-10-PCS
Code(s) Assigned
51.51 Other incision of bile duct, exploration of
0FJB0ZZ
common duct
0 Medical and surgical section (procedure type)
F Hepatobiliary system and pancreas (body system)
J Inspection (root operation)
B Hepatobiliary Duct
0 Open (approach)
Z None (device)
Z None (qualifier)
Index and Tabular Volumes
Alphabetic Index:
Alphabetic Index:
Exploration – see Inspection
Exploration – see also Incision
common bile duct 51.51
Inspection
Duct
Hepatobiliary 0FJB
Tabular (Tables):
Reference the table for 0FJ (see the Excerpt from the
ICD-10-PCS Tables) to look up the remaining
characters of the code. In this case the specific body
part is the hepatobiliary duct (9), the approach is open
(0), and there is no device or qualifier (Z).
Code Comparisons
No further classification as to operative
 The code specifies that the inspection of the
approaches
common bile duct was done during an open
approach
Documentation Needed
Documentation specifying the common bile
 Documentation must clearly describe the
duct was explored
approach to accurately assign the fifth character
 Definition of “inspection”
Tabular:
51.5 Other incision of bile duct
51.51 Exploration of common duct
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
Excerpt from the ICD-10-PCS Tables
0: Medical and Surgical
F: Hepatobiliary System and Pancreas
J: Inspection: Visually and/or manually exploring a body part
Body Part
Character 4
0 Liver
1 Liver, right lobe
2 Liver, left lobe
3 Liver, caudate lobe
4 Gallbladder
G Pancreas
5 Hepatic duct, right
6 Hepatic duct, left
7 Hepatic duct, caudate
8 Cystic duct
9 Common bile duct
B Hepatobiliary duct
C Ampulla of Vater
D Pancreatic duct
F Pancreatic duct, Accessory
Approach
Character 5
Device
Character 6
Qualifier
Character 7
0 Open
3 Percutaneous
4 Percutaneous
Endoscopic
X External
Z No Device
No Qualifier
0 Open
2
3 Percutaneous
4 Percutaneous
Endoscopic
7 Via Natural or Artificial
Opening
8 Via Natural or Artificial
Opening Endoscopic
Z No Device
Z No Qualifier
17. Coronary artery bypass graft (CABG) x 3 using saphenous vein grafts, with
cardiopulmonary bypass
ICD-9-CM
ICD-10-PCS
Code(s) Assigned
36.13 (Aorto)coronary bypass of three coronary
021209W
arteries
0 Medical and surgical section (procedure type)
39.61 Cardiopulmonary bypass
2 Heart and great vessels (body system)
1 Bypass (root operation)
2 Coronary arteries, three sites (body part)
0 Open (approach)
9 Autologous venous tissue (device)
W Aorta (qualifier)
05A1221Z
5 Extracorporeal Assistance and Performance
(procedure type)
A Physiological Systems (body system)
1 Performance (root operation)
2 Cardiac (body part)
2 Continuous (duration)
1 Output (device)
Z None (qualifier)
5A1935Z
5 Extracorporeal Assistance and Performance
(procedure type)
A Physiological Systems (body system)
1 Performance (root operation)
9 Respiratory (body part)
3 Less than 24 Consecutive Hours (duration)
5 Ventilation (function)
Z No Qualifier (qualifier)
Index and Tabular Volumes
Alphabetic Index:
Alphabetic Index:
Bypass
Bypass
by Body Part
aortocoronary (catheter stent) (with
Artery
prosthesis) (with saphenous vein graft) (with
Coronary, Three Sites 0212
vein graft)
three coronary vessels 36.13
Extracorpeal Assistance and Performance
– see Performance
Bypass
cardiopulmonary 39.61
Performance
Cardiac
Continuous
Output 5A1221Z
Performance
Respiratory
Less than 24 consecutive hours, ventilation
5A1935Z
Tabular:
36.1 Bypass anastomosis for heart
revascularization
Code also any:
Cardiopulmonary bypass (39.61)
36.13 (Aorta)coronary bypass of three
coronary arteries
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



Tabular (Tables):
Reference the table for 021 (see the Excerpt from
ICD-10-PCS Tables) to look up the remaining
characters of the code. In this case the specific body
part is coronary arteries, three (2), the approach is
open (9), the device is autologous venous tissue
(saphenous vein grafts) (9), and the qualifier is the
aorta (W).
Reference the table for 5A1 (see the Excerpt from
39.61 Extracorporeal circulation auxiliary
the ICD-10-PCS Tables) to look up the remaining
to open heart surgery
characters of the code. In this case the body part is
cardiac (2), the duration is continuous (2), the
function is output (1), and the qualifier is none (Z).
Lastly reference the table for 5A1 (see the Excerpt
from the ICD-10-PCS Tables) to look up the
remaining characters of the code. In this case the
body part is respiratory (9), the duration is less than
24 consecutive hours (3), the function is ventilation
(5) and the qualifier is none (Z).
Code Comparisons
One subcategory: 36.1x
 Four subcategories:
0210 (one coronary artery)
Differentiated by number of grafts only
0211 (two coronary arteries)
Additional code required for cardiopulmonary
0212 (three coronary arteries)
bypass
0213 (four or more coronary arteries)
 Differentiated by number of grafts, open versus
percutaneous endoscopic and type of graft
 Additional code required for cardiopulmonary
bypass
Documentation Needed
Number of aortocoronary grafts
 Number of aortocoronary grafts
Use of cardiopulmonary bypass
 Open versus closed
 Use of cardiopulmonary bypass
 Type of graft used
Excerpt from ICD-10-PCS Tables
0: Medical and Surgical
2: Heart and Greater Vessels
1: Bypass Altering the route of passage of the contents of a tubular body part
Body Part
Approach
Device
Qualifier
Character 4
Character 5
Character 6
Character 7
0
1
2
3
Coronary Artery, One Site
Coronary Artery, Two Sites
Coronary Artery, Three Sites
Coronary Artery, Four or
More Sites
0
Open
9 Autologous Venous
Tissue
A Autologous Arterial
Tissue
J Synthetic Substitute
K Nonautologous Tissue
Substitute
3 Coronary Artery
8 Internal Mammary,
Right
9 Internal Mammary,
Left
C Thoracic Artery
F Abdominal Artery
W Aorta
Excerpt from ICD-10-PCS Tables
5: Extracorporeal Assistance and Performance
A: Physiological Systems
1: Performance Completely taking over a physiological function by extracorporeal means
Body Part
Character 4
Duration
Character 5
Device
Character 6
Qualifier
Character 7
2 Cardiac
0 Single
1 Output
2 Manual
2 Cardiac
1 Intermittent
3 Pacing
Z No Qualifier
2 Cardiac
2 Continuous
Z No Qualifier
9 Respiratory
3 Less than 24
Consecutive Hours
4 24-96 Consecutive
Hours
5 Greater than 96
Consecutive Hours
1 Output
3 Pacing
5 Ventilation
Z No Qualifier
18. Postoperative pulmonary artery embolism, initial encounter
ICD-9-CM
ICD-10-CM
Code(s) Assigned
415.11 Iatrogenic pulmonary embolism and
T81.718A Complication of other artery following a
infarction
procedure, not elsewhere classified, initial
encounter
I26.99 Other pulmonary embolism without acute
cor pulmonale
Index and Tabular Volumes
Alphabetic Index:
Alphabetic Index:
Embolism
Embolism
pulmonary (artery) (vein)
postoperative
postoperative 415.11
artery
specified NEC T81.718
Complication
respiratory
Embolism
postoperative NEC 997.39
pulmonary (artery)(vein) I26.99
Tabular:
415.11 Iatrogenic pulmonary embolism and
infarction
997.3 Respiratory complications
Excludes: iatrogenic pulmonary embolism
(415.11)
Tabular:
T81 Complications of procedures, not
elsewhere classified
The appropriate seventh character is to be
Added to each code from category T81:
A initial encounter
D subsequent encounter
S sequela
T81.718 Complication of other artery
following a procedure, not
elsewhere classified
I26 Pulmonary embolism
Excludes 2: pulmonary embolism due to
complications of surgical and
medical care (T80.0, T81.7-,
T82.8-)
Code Comparisons
 Classified as a disease of pulmonary system
 Classified as a complication of surgical and
(section 415–417)
medical care (Section T80–T88)
 Code description specifically denotes
 Code description does not specifically denote
pulmonary embolism
pulmonary embolism
 Seventh character specifies the episode of
care (encounter)
Documentation Needed
Diagnosis of pulmonary embolism specified as
 Diagnosis of pulmonary embolism following a
postoperative
surgical procedure
 Indication of the episode of care (encounter)
19. Aftercare encounter for management of a subtrochanteric fracture of the left femur. Patient
fell and fractured the left femur two weeks earlier.
ICD-9-CM
ICD-10-CM
Code(s) Assigned
V54.13 Aftercare for healing traumatic fracture of
S72.22xD Displaced subtrochanteric fracture of left
hip
femur, subsequent encounter for closed fracture with
routine healing
W19.xxxD Fall, falling (accidental)
Index and Tabular Volumes
Alphabetic Index:
Alphabetic Index:
Aftercare
Aftercare
fracture
fracture–code to fracture with extension D
healing
traumatic
Fracture, traumatic
hip V54.13
femur
subtrochanteric (region) (section) (displaced)
S72.2External Cause Index
Fall, falling (accidental) W19
Tabular:
V54.13 Aftercare for healing traumatic fracture
of hip
Tabular:
S72 Fracture of femur
A fracture not indicated as displaced or
nondisplaced should be coded as displaced
A fracture not designated as open or closed
should be coded to closed
The appropriate seventh character is to be
added to each code from category S72
(following is part of list of seventh character):
A initial encounter for closed fracture
D subsequent encounter for closed fracture with
routine healing
K subsequent encounter for closed fracture with
nonunion
P subsequent encounter for closed fracture with
malunion
S sequela
S72.22 Displaced subtrochanteric fracture
of left femur
W19 Unspecified fall
The appropriate 7th character is to be added to
code W19:
A – initial encounter
D – subsequent encounter
S - sequelae





Code Comparisons
Traumatic fractures are coded using the acute
 Codes that represent reasons for encounters are
fracture codes (800–829) while the patient is
Z codes not V codes
receiving active treatment for the fracture
 Z codes for aftercare are not used if treatment is
Fractures are coded using aftercare codes
directed at the current injury––instead, the injury
(subcategories V54.0, V54.1, V54.2, or V54.8)
code should be reported with a seventh
for encounters after the patient has completed
character extension to signify subsequent
active treatment of the fracture and is receiving
encounter
routine care for the fracture during the healing
 The injury code specifies laterality
or recovery phase
 Extension codes must always be the seventh
Subcategories V54.1 (aftercare for healing
character; to apply an extension to a code that is
traumatic fracture) and V54.2 (aftercare for
not a full six characters, a lower case x is utilized
healing pathologic fracture) have been created
as a placeholder
to identify the fracture site being treated
Documentation Needed
The purpose for the encounter (that is, initial
 The purpose for the encounter (that is, initial
encounter versus subsequent)
encounter versus subsequent)
The general type and location of the fracture
 The specific type and location of the fracture
21. Diagnostic left-heart catheterization
ICD-9-CM
ICD-10-PCS
Code(s) Assigned
37.22 Left heart cardiac catheterization
4A023N7
4 Measurement and monitoring (procedure type)
A Physiological systems (body system)
0 Measurement (root operation)
2 Cardiac (body system)
3 Percutaneous (approach)
N Sampling and pressure (function/device)
7 Left heart (qualifier)
Index and Tabular Volumes
Alphabetic Index:
Alphabetic Index:
Catheterization
cardiac
Catheterization
Heart, see Measurement, Cardiac 4A02
left 37.22
Measurement
Cardiac
Sampling and Pressure
Left Heart 4A02
Tabular:
37.2 Diagnostic procedures on heart and
pericardium
37.22 Left heart cardiac catheterization
Tabular (Tables):
Reference the table for 4A0 (see the Excerpt from
ICD-10-PCS Tables) to look up the remaining
characters of the code. In this case the approach is
percutaneous (3), the function/device is sampling
and pressure (N), and the qualifier is the left heart
(7).





Code Comparisons
One code category; 37 Other operations on
 Fourth character classifies body system (cardiac)
heart and pericardium
 Fifth character classifies the approach
Third digit classification based on the type of
 Sixth character for function/device used
operation performed
 Seventh character classifies area of heart that
Fourth digit differentiates the part of heart; left
was catheterized (left, right, bilateral)
or right
Documentation Needed
Type of procedure performed
 Reason for procedure
Side of the heart procedure performed on:
 Type of procedure performed
o Left
 Approach used
o Right
o Open
o Combined
o Percutaneous
 Side of the heart procedure performed on
o Left
o Right
o Bilateral
 Function or type of device used
Excerpt from ICD-10-PCS Tables
4: Measurement and Monitoring
A: Physiological Systems
0: Measurement Determining the level of a physiological or physical function at a point in time
Body System
Approach
Function/Device
Qualifier
Character 4
Character 5
Character 6
Character 7
2 Cardiac
0 Open
3 Percutaneous
2 Cardiac
0 Open
3 Percutaneous
2 Cardiac
X External
2 Cardiac
X External
4
9
C
F
H
P
N
Electrical Activity
Output
Rate
Rhythm
Sound
Action Currents
Sampling and Pressure
4 Electrical Activity
9 Output
C Rate
F Rhythm
H Sound
P Action Currents
M Total Activity
Z No Qualifier
6
7
8
Z
Right Heart
Left Heart
Bilateral
No Qualifier
4 Stress
22. Down’s syndrome
ICD-9-CM
758.0 Down’s syndrome
ICD-10-CM
Code(s) Assigned
Q90.9 Down’s syndrome, unspecified
Index and Tabular Volumes
Alphabetic Index:
Alphabetic Index:
Down syndrome Q90.9
Down’s disease or syndrome (mongolism) 758.0
Syndrome
Down’s (mongolism) 758.0
Syndrome
Down (see also Down syndrome) Q90.9
Tabular:
758 Chromosomal anomalies
Use additional codes for conditions associated
with the chromosomal anomalies
Tabular:
Q90 Down Syndrome
Q90.0 Trisomy 21, nonmosaicism
Q90.1 Trisomy 21, mosaicism
Q90.2 Trisomy 21, translocation
Q90.9 Down’s syndrome, unspecified
758.0 Down’s syndrome
Mongolism
Translocation Down’s Syndrome
Trisomy:
21 or 22
G



Code Comparisons
One category, 758, Chromosomal abnormalities  Multiple categories (Q90–Q99) for chromosomal
abnormalities
Classification based on the Trisomy number
Documentation Needed
Documentation of type of chromosomal
 Documentation of type of chromosomal
abnormality
abnormality
27. Left liver lobectomy, open
Supporting documentation: The operative report indicates the surgeon removed the entire
left lobe of the liver
ICD-9-CM
50.3 Lobectomy of liver
ICD-10-PCS
Code(s) Assigned
0FT20ZZ
0 Medical and surgical section (procedure
type)
F Hepatobiliary system and pancreas (body
system)
T Resection (root operation)
2 Liver, left lobe (body part)
0 Open (approach)
Z None (device)
Z None (qualifier)
Index and Tabular Volumes
Alphabetic Index:
Alphabetic Index:
Lobectomy
Lobectomy
– see Resection, Hepatobiliary Systems and
liver (with partial excision of adjacent lobes) 50.3
Pancreas
Resection
Liver
Left lobe 0FT2
Tabular (Tables):
Tabular:
50.3 Lobectomy of liver
Reference the table for 0FT (see the Excerpt from
Total hepatic lobectomy with partial excision of ICD-10-PCS Tables) to look up the remaining
other lobe
characters of the code. In this case the specific
body part is the left lobe of the liver (2), the
approach is open (0), and there is no device or
qualifier (Z).
Code Comparisons
 Lobe laterality not defined
 Approach of the procedure is defined in the
code, open versus percutaneous endoscopic
 Approach not defined
 Code includes partial lobectomy of another lobe  Lobe laterality is required for proper code
assignment
of the liver
Documented Needed
 The entire lobe was removed
 Laterality of lobe that was removed
 The approach used to remove the lobe
 Whether or not the entire lobe (resection) or
part of the lobe (excision) was removed
Excerpt from ICD-10-PCS Tables
0: Medical and Surgical
F: Hepatobiliary System and Pancreas
T: Resection
Cutting out or off, without replacement, all of a body part
Body System
Approach
Device
Qualifier
Character 4
Character 5
Character 6
Character 7
0 Liver
1 Liver, Right Lobe
2 Liver, Left Lobe
4 Gallbladder
G Pancreas
0 Open
4 Percutaneous
Endoscopic
Z
No Device
Z No Qualifier
29. Excision of fallopian tubes, bilateral, endoscopic
ICD-9-CM
ICD-10-PCS
Code(s) Assigned
66.51 Bilateral excision of fallopian tubes
0UT74ZZ
0 Medical and surgical section (procedure type)
U Female reproductive system (body system)
T Resection (root operation)
7 Fallopian tubes, bilateral (body part)
4 Percutaneous endoscopic (approach)
Z None (device)
Z None (qualifier)
Index and Tabular Volumes
Alphabetic Index:
Alphabetic Index:
Salpingectomy (bilateral) (total) (transvaginal)
Salpingectomy
66.51
– see Excision, Female Reproductive System 0UB
– see Resection, Female Reproductive System 0UT
Resection
Fallopian Tubes, Bilateral 0UT7
Tabular:
66.5 Total bilateral salpingectomy
66.51 Removal of both fallopian tubes at
same operative episode





Tabular (Tables):
Reference the table for 0UT (see the Excerpt from ICD10-PCS Tables) to look up the remaining characters of
the code. In this case, the specific body part is the
fallopian tubes, bilateral (7), the approach is
percutaneous endoscopic (4), and there is no device or
qualifier (Z).
Code Comparisons
Differentiated by single, bilateral tube removal
 The specific approach for the procedure is identified
The approach is not identified
 Identifies bilateral or unilateral removal of tube
Documentation Needed
Total or partial excision
 Total (resection) or partial (excision) removal
Diagnostic reason for excision
 Bilateral or unilateral excision; if unilateral then right
or left
Bilateral or unilateral excision
 Operative approach
Excerpt from ICD-10-PCS Tables
0: Medical and Surgical
U: Female Reproductive System
T: Resection
Cutting out or off, without replacement, all of a body part
Body System
Approach
Device
Qualifier
Character 4
Character 5
Character 6
Character 7
0
1
2
5
6
7
9
Ovary, Right
Ovary, Left
Ovaries, Bilateral
Fallopian Tube, Right
Fallopian Tube, Left
Fallopian Tubes, Bilateral
Uterus
0 Open
4 Percutaneous
Endoscopic
7 Via Natural or
Artificial Opening
8 Via Natural or Artificial
Opening Endoscopic
F Via Natural or Artificial
Opening With
Percutaneous
Endoscopic
Assistance
Z
No Device
Z No Qualifier
31. Right kidney transplantation, open, zooplastic donor
ICD-9-CM
ICD-10-PCS
Code(s) Assigned
55.69 Other Kidney Transplantation
0TY00Z2
0 Medical and surgical section (procedure type)
T Urinary system (body system)
Y Transplantation (root operation)
0 Kidney, right (body part)
0 Open (approach)
Z None (device)
2 Zooplastic (qualifier)
Index and Tabular Volumes
Alphabetic Index:
Alphabetic Index:
Transplant, Transplantation
Transplantation
kidney NEC 55.69
Kidney
Right 0TY00Z
Tabular:
55.6 Transplant of kidney
Note: To report donor source—see codes
00.91–00.93
55.69 Other kidney transplantation
Tabular (Tables):
Reference the table for 0TY (see the Excerpt from
ICD-10-PCS Tables) to look up the remaining
characters of the code. In this case the specific
body part is the right kidney (0), the approach is
open (0), the devices is none (Z), and the qualifier is
zooplastic donor (2).






Code Comparisons
Only one code is offered for a kidney
 Multiple codes are included for kidney
transplantation (55.69 NEC).
transplantation
Additional codes for donors only include
 Code distinguishes which kidney was
transplants from live related donor, live
transplanted
nonrelated donor, and from a cadaver.
 Code specifies the approach
Nonspecific as to type of approach
 More options for donor source are available and
Nonspecific as to which kidney is
included in the code eliminating the need for a
transplanted (right or left)
second code
Documentation Needed
Organ that was transplanted
 Which organ was transplanted including if it was
right or left
Donor source
 Approach used
 Donor source
Excerpt from ICD-10-PCS Tables
0: Medical and Surgical
T: Urinary System
Y: Transplantation Putting in or on all or a portion of a living body part taken from another
individual or animal to physically take the place and/or function of all or
a portion of a similar body part.
Body System
Approach
Device
Qualifier
Character 4
Character 5
Character 6
Character 7
0
1
Kidney, Right
Kidney, Left
0 Open
Z
No Device
0
1
2
Allogeneic
Syngeneic
Zooplastic
33.Classical migraine
ICD-9-CM
ICD-10-CM
Code(s) Assigned
346.00 Classical migraine, without mention of
G43.109 Migraine with aura, not intractable,
intractable migraine, without mention of status
without status migrainosus
migrainosus
Index and Tabular Volumes
Alphabetic Index:
Alphabetic Index:
Migraine
Migraine
classic(al) 346.0
Classical – see Migraine, with aura
Migraine
with aura (acute-onset) (prolonged) (typical)
(without headache) G43.109
Tabular:
346 Migraine
The following fifth-digit subclassification is for
use with category 346:
0 without mention of intractable migraine
without mention of status migrainosus
1 with intractable migraine, so stated without
mention of status migrainosus
2 without mention of intractable migraine with
status migrainosus
3 with intractable migraine, so stated, with
status migrainosus
Tabular:
G43 Migraine
G43.10 Migraine, with aura, not
intractable
Classic migraine
G43.109 Migraine, with aura, not
intractable, without
status migrainosus
346.0 Migraine with aura
Classic migraine




Code Comparisons
One code category with subcategories at the
 One combination code which classifies the
fourth digit level for the type of migraine
type of migraine, whether or not intractable
and whether or not with status migrainosus
Fifth digit specifies with or without intractable
migraine and with or without status migrainosus

Documentation Needed
Diagnosis of migraine
 Diagnosis of migraine
Documentation of whether migraine is intractable  Documentation of whether migraine is
intractable and status migrainosis
and status migrainosius
35. Macular degeneration, atrophic
ICD-9-CM
ICD-10-CM
Code(s) Assigned
362.51 Exudative senile macular degeneration
H35.30 Unspecified macular degeneration (agerelated)
Index and Tabular Volumes
Alphabetical Index:
Alphabetical Index:
Degeneration, degenerative
Degeneration, degenerative
macula (acquired) (senile)
macula, macular (acquired) (atrophic) (exudative)
atrophic 362.51
(senile) H35.30
Tabular:
Tabular:
362.5 Degeneration of macula and posterior
H35.3 Degeneration of macula and posterior pole
pole
H35.30 Unspecified macular degeneration
362.51 Nonexudative senile macular
(age related)
degeneration
Code Comparisons
 One code subcategory for degeneration of
 One code subcategory for degeneration of
macula and posterior pole
macula and posterior pole
 Fifth digit provides further specification of
 Fifth character provides further specification of
complications
complications
 Some codes are further subdivided with a sixth
character specifying right, left, bilateral, or
unspecified eye
Documentation Needed
 Any complications or manifestations of the
 Any complications or manifestations of the
degeneration
degeneration
 Type of degeneration
 Type of degeneration
 Which eye(s) has manifestation or unspecified
36. Cervical esophagostomy, open
ICD-9-CM
42.11 Cervical esophagostomy
Alphabetical Index:
Esophagostomy
cervical 42.11
ICD-10-PCS
Code(s) Assigned
0D110Z4
0 Medical and surgical (procedure type)
D Gastrointestinal system (body system)
1 Bypass (root operation)
1 Esophagus, upper (body part)
0 Open (approach)
Z None (device)
4 Cutaneous (qualifier)
Index and Tabular Volumes
Alphabetical Index:
Esophagostomy
– see Bypass, Gastrointestinal System 0D1
Bypass
Tabular:
42.1 Esophagostomy
42.11 cervical esophagostomy
Esophagus
Upper 0D11
Tabular (Tables):
Reference the table for 0D1 (see Excerpt from the
ICD-10-PCS Tables) to look up the remaining
characters of the code. In this case the specific
body part is esophagus upper (1), the approach is
open (0), the device is none (Z), and the qualifier is
cutaneous (4).
Code Comparisons
 One code category with subcategories at the
 Classification differentiates the three sections of
fourth character level for further specification
the esophagus (upper, middle, and lower)
 Classification does not specify the approach
 Code specifies the operative approach
 Code specifies any devices remaining at the end
of the operation
 Code specifies the destination of the bypass
(qualifier)
Documentation Needed
 Location or site of the esophagostomy
 Location or site of the esophagostomy
 Operative approach
 Any devices remaining at the end of the operation
 The destination of the bypass
Excerpt from ICD-10-PCS Tables
0: Medical and Surgical
D: Gastrointestinal System
1: Bypass:
Altering the route of passage of the contents of a tubular body part
Body System
Approach
Device
Qualifier
Character 4
Character 5
Character 6
Character 7
1
2
3
5
Esophagus, upper
Esophagus, middle
Esophagus, lower
Esophagus
0 Open
4 Percutaneous
Endoscopic
8 Via Natural or Artificial
Opening Endoscopic
7 Autologous Tissue
Substitute
J Synthetic Substitute
K Nonautologous Tissue
Substitute
Z No Device
4
6
9
A
B
Cutaneous
Stomach
Duodenum
Jejunum
Ileum
40. Crush syndrome with hemorrhaging; lacerations of small and large intestines. Ten-year-old
patient was rough housing with his brother in the shop and a sheet of drywall accidentally fell on
the patient. The patient was immediately sent to the operating room where an open repair of the
lacerations of the small and large intestines due to the crushing injury was performed (code both
diagnosis and procedure codes)
ICD-9-CM
ICD-10-CM
Diagnosis Code(s) Assigned
958.5 Traumatic anuria
T79.5xxA Traumatic anuria, initial encounter
459.0 Hemorrhage, unspecified
R58 Hemorrhage, not elsewhere classified
863.30 Injury to small intestine, with open wound
S36.439A Laceration of unspecified part of small
into cavity, unspecified site
intestine, initial encounter
863.50 Injury to colon, with open wound into cavity,
S36.539A Laceration of unspecified part of colon,
unspecified site
initial encounter
E916 Struck accidently by falling object
W20.8xxA Other cause of strike by thrown, projected,
E849.3 Place of occurrence, industrial place and
or falling object
premises
Y92.513 Shop as the place of occurrence of the
E029.2 Rough housing and horseplay
external cause
E000.8 Other external cause status
Y93.83 Activity, rough housing and horseplay
Y99.8 Other external cause status
Index and Tabular Volumes
Alphabetic Index:
Alphabetic Index:
Syndrome
Syndrome
Crush T79.5
Crush 958.5
Hemorrhage, hemorrhagic 459.0
Laceration
internal organ (abdomen) (chest) (pelvic) NEC –
see Injury, internal, by site
Hemorrhage, hemorrhagic R58
Laceration
intestine
large
colon S36.539
small S36.439
Injury
Internal
intestine NEC
large NEC
with open wound into cavity 863.50
small NEC
with open wound into cavity 863.30
Index to External Causes:
Hit, hitting by
object
falling E916
Accident (to)
occurring
shop E849.3
Index to External Causes:
Struck by
object
falling W20.8
Place of occurrence
shop Y92.513
Activity
rough housing and horseplay E029.2
External Cause Status
specified NEC E000.8
Tabular:
958 Certain early complications of trauma
958.5 Traumatic anuria
Crush syndrome
459 Other disorders of circulatory system
459.0 Hemorrhage, unspecified
Internal Injury of Thorax, Abdomen, and Pelvis
(860–869)
Includes: laceration of internal organs
863 Injury to gastrointestinal tract
863.3 Small intestine, with open wound
into cavity
864.30 Small intestine, unspecified
site
863.5 Colon or rectum, with open wound
into cavity
863.50 Colon, unspecified site
E916 Struck accidentally by falling object
E849 Place of occurrence
E849.3 Industrial place and premises
Shop
E029 Other Activity
E029.2 Rough housing and horseplay
E000 External cause status
E000.8 Other external cause status
Activity
rough housing and horseplay Y93.83
External Cause Status
specified NEC Y99.8
Tabular:
T79 Certain early complications of trauma, not
elsewhere classified
The appropriate seventh character is to be added
to each code from category T79:
A initial encounter
D subsequent encounter
S sequela
T79.5 Traumatic anuria
Crush syndrome
R58 Hemorrhage, not elsewhere classified
Includes: hemorrhage NOS
Excludes 1: hemorrhage included with underlying
conditions, such as:
acute duodenal ulcer with
hemorrhage (K26.0)
acute gastritis with bleeding (K29.01)
ulcerative enterocolitis with rectal
bleeding (K51.01)
S36 Injury of intra-abdominal organs
Code also any associated open wound (S31.-)
The appropriate seventh character is to be added
to each code from category S36:
A initial encounter
D subsequent encounter
S sequela
S36.4 Injury of small intestine
S36.43 Laceration of small intestine
S36.439 Laceration of
unspecified part of
small intestine
S36.5 Injury of colon
S36.53 Laceration of colon
S36.539 Laceration of
unspecified part of colon
W20 Struck by thrown, projected, or falling object
The appropriate seventh character is to be
added to each code from category W20:
A initial encounter
D subsequent encounter
S sequela
W20.8 Other cause of strike by thrown,
projected, or falling object
Y92.513 Shop as the place of occurrence of the
external cause
Y93 Activity Codes
Y93.8 Activities, other specified
Y93.83 Activity, rough housing and horseplay

Y99 External Cause Status
Y99.8 Other external cause status
Code Comparisons
Laceration of an internal organ is classified as
 Laceration of an internal organ is classified as a
injury of the organ with open wound into the
laceration to that internal organ with a separate
cavity
code for any associated open wound of the
abdominal wall
Documentation Needed
 Documentation of site of laceration
 Documentation of specific site of large and small
intestine that were lacerated
 External cause of the injury and place of
 Whether or not there was an associated open
occurrence in additional to type of activity being
performed
wound of the abdominal wall
 External cause of the injury and place of
occurrence in addition to type of activity being
performed
ICD-9-CM
ICD-10-PCS
Procedure Code(s) Assigned
0DQ80ZZ Repair of small intestines
46.73 Suture of laceration of small intestine
0 Medical and surgical section (procedure type)
46.75 Suture of laceration of large intestine
D Gastrointestinal system (body system)
Q Repair (root operation)
8 Small intestines (body part)
0 Open (approach)
Z None (device)
Z None (qualifier)
0DQE0ZZ Repair of large intestines
0 Medical and surgical section (procedure type)
D Gastrointestinal system (body system)
Q Repair (root operation)
E Large intestine (body part)
0 Open (approach)
Z None (device)
Z None (qualifier)
Alphabetic Index:
Repair
laceration – see Suture, by site
Index and Tabular Volumes
Alphabetic Index:
Suture –
Laceration repair see Repair
Suture (laceration)
intestine
large 46.75
small 46.73
Tabular:
46.7 Other repair of intestine
46.73 Suture of laceration of small
intestine, except duodenum




Repair
Intestine
Large 0DQE
Small 0DQ8
Tabular (Tables):
Reference the table for 0DQ (see the Excerpt from
ICD-10-PCS Tables) to look up the remaining
characters of the code. In this case the specific body
parts are the large intestine (E) and small intestine (8),
46.75 Suture of laceration of large intestine
the approach is open (0), and there is no device or
qualifier (Z).
Code Comparisons
Classification only provides three codes for
 Classification provides a code for each specific
suture repair of laceration of small and large
body part of the small intestine and large intestines
intestine:
 Classification includes the approach
o Small intestines
o Large intestines
o Duodenum
Classification does not provide the ability to
differentiate suture repair of specific parts of
small and large intestines except for duodenum
Classification does not differentiate the approach
Documentation Needed
Location of laceration and suture repair
 Location of laceration and suture repair
 Approach
Excerpt from ICD-10-PCS Tables
0: Medical and Surgical
D: Gastrointestinal System
Q: Repair
Restoring, to the extent possible, a body part to its normal anatomic
structure and function
Body System
Approach
Device
Qualifier
Character 4
Character 5
Character 6
Character 7
1
2
3
4
5
6
7
8
9
A
B
C
E
F
G
H
J
K
L
M
N
P
Esophagus, Upper
Esophagus, Middle
Esophagus, Lower
Esophagogastric Junction
Esophagus
Stomach
Stomach, Pylorus
Small Intestine
Duodenum
Jejunum
Ileum
Ileocecal Valve
Large Intestine
Large Intestine, Right
Large Intestine, Left
Cecum
Appendix
Ascending Colon
Transverse Colon
Descending Colon
Sigmoid Colon
Rectum
0
Open
3
4
Percutaneous
Percutaneous
Endoscopic
Via Natural or
Artificial Opening
Via Natural or
Artificial Opening
Endoscopic
7
8
Z
No Device
Z
No Qualifier
42. Laparoscopic cholecystectomy, converted to an open procedure
ICD-9-CM
ICD-10-PCS
Code(s) Assigned
V64.41 Laparoscopic surgical procedure
0FT40ZZ
converted to open procedure
0 Medical and surgical section (procedure type)
51.22 Cholecystectomy
F Hepatobiliary system and pancreas (body
system)
T Resection (root operation)
4 Gallbladder (body part)
0 Open (approach)
Z None (device)
Z None (qualifier)
0FJ44ZZ
0 Medical and surgical section (procedure type)
F Hepatobiliary System and Pancreas (body
system)
J Inspection (root operation)
4 Gallbladder (body part)
4 Percutaneous endoscopic (approach)
Z None (device)
Z None (qualifier)
Index and Tabular Volumes
Alphabetic Index:
Alphabetic Index (Diseases):
Laparoscopic surgical procedure converted
Cholecystectomy
to open procedure V64.41
– see Resection, Gallbladder 0FT4
Alphabetic Index (Procedures):
Cholecystectomy (total) 51.22
Resection
Gallbladder 0FT4
Inspection
Gallbladder 0FJ4
Tabular (Diseases):
V64.41 Laparoscopic surgical procedure
converted to open procedure
Tabular (Procedures):
51.2 Cholecystectomy
51.22 Cholecystectomy
Tabular (Tables):
Reference the table for 0FT (see the Excerpt from
ICD-10-PCS Tables) to look up the remaining
characters of the code. In this case the specific
body part is the gallbladder (4), the approach is
open (0), and there is no device or qualifier (Z).
Reference the table for 0FJ (see the Excerpt from
ICD-10-PCS Tables) to look up the remaining
characters of the code. In this case the specific
body part is the gallbladder (4), the approach is
percutaneous endoscopic (4), and there is no
device or qualifier (Z).





Code Comparisons
In ICD-9-CM when a laparoscopic procedure  In ICD-10-PCS when a laparoscopic procedure
is converted to an open procedure, the
is converted to an open procedure, the coding
coding rule is to only code the open
rule is to code an endoscopic inspection (for
procedure and assign V64.41 as an
laparoscopic procedure) and then code the
additional diagnosis code
actual open procedure
Type of approach is not classified except for
 Approach is specified
laparoscopic
Fourth digit indicates laparoscopic partial or
total or other partial cholecystectomy
Documentation Needed
Laparoscopic procedure converted to open
 Laparoscopic procedure converted to open
Whether total or partial excision
 Approach for the procedure
 Whether total (resection) or partial (excision)
Excerpt from ICD-10-PCS Tables
0: Medical and Surgical
F: Hepatobiliary System and Pancreas
T: Resection
Cutting out or off, without replacement, all of a body part
Body System
Approach
Device
Qualifier
Character 4
Character 5
Character 6
Character 7
0
1
2
Liver
Liver, Right Lobe
Liver, Left Lobe
4
G
Gallbladder
Pancreas
0
4
Open
Percutaneous
Endoscopic
Z
No Device
Z
No Qualifier
Excerpt from ICD-10-PCS Tables
0: Medical and Surgical
F: Hepatobiliary System and Pancreas
T: Inspection
Visually and/or manually exploring a body part
Body System
Approach
Device
Character 4
Character 5
Character 6
0
1
2
4
G
Liver
Liver, Right Lobe
Liver, Left Lobe
Gallbladder
Pancreas
0
3
4
X
Open
Percutaneous
Percutaneous
Endoscopic
External
Z
No Device
Qualifier
Character 7
Z
No Qualifier
44. Atherosclerotic heart disease of native coronary artery; unstable angina pectoris
ICD-9-CM
ICD-10-CM
Code(s) Assigned
414.01 Atherosclerotic heart disease of native
I25.110 Atherosclerotic heart disease of native
coronary artery
coronary artery with unstable angina pectoris
411.1 Unstable angina
Index and Tabular Volumes
Alphabetic Index:
Alphabetic Index:
Atherosclerosis – see Arteriosclerosis
Atherosclerosis – see also Arteriosclerosis
coronary artery I25.10
Arteriosclerosis, arteriosclerotic
with angina pectoris – see also Arteriosclerosis,
heart (disease) (see also Arteriosclerosis,
coronary (artery)
coronary)
coronary (artery) 414.00
Arteriosclerosis, arteriosclerotic
native artery 414.01
coronary (artery) I25.10
native vessel
with
Angina
angina pectoris I25.119
Unstable 411.1
specified type NEC I25.118
unstable I25.110
Tabular:
414.0 Coronary atherosclerosis:
Arteriosclerotic heart disease [ASHD]
Atherosclerotic heart disease
Coronary (artery):
arteriosclerosis
arteritis or endarteritis
atheroma
sclerosis
stricture
Use additional code, if applicable, to identify
chronic total occlusion of coronary artery
(414.2)
414.01 Of native coronary artery
411.1 Intermediate coronary syndrome:
Impending infarction
Preinfarction angina
Preinfarction syndrome
Unstable angina
Tabular:
I25.1 Atherosclerotic heart disease of native
coronary artery
Atherosclerotic cardiovascular disease
Coronary (artery) atheroma
Coronary (artery) atherosclerosis
Coronary (artery) disease
Coronary (artery) sclerosis
Excludes2: atheroembolism (I75.-)
atherosclerosis of coronary artery
bypass graft(s) and transplanted
heart (I25.7-)
I25.10 Atherosclerotic heart disease of
native coronary artery without angina
pectoris
Atherosclerotic heart disease NOS
I25.11 Atherosclerotic heart disease of
native coronary artery with angina
pectoris
I25.110 Atherosclerotic heart disease
of native coronary artery with
unstable angina pectoris
Excludes 1: unstable angina
without atherosclerotic heart
disease (I20.0)




Code Comparisons
In ICD-9-CM, two codes are required to code
 Only one code is needed to represent all of the
atherosclerotic heart disease of native
detail concerning this condition
coronary artery; unstable angina pectoris
 Combination codes are common in ICD-10-CM
Because two codes are required to fully
describe the condition, this may result in a
sequencing dilemma; many issues of Coding
Clinic have addressed this issue
Documentation Needed
Type of ASHD (native versus bypass graft)
 Type of ASHD (native versus bypass graft)
Type of angina
 Type of angina
46. Patient with a large splenic mass is admitted for a laparoscopic splenectomy (code both
diagnosis and procedure codes)
ICD-9-CM
789.2 Splenomegaly
ICD-10-CM
Diagnosis Code(s) Assigned
R16.1 Splenomegaly, not elsewhere classified
Alphabetic Index:
Mass
splenic 789.2
Index and Tabular Volumes
Alphabetic Index:
Mass
splenic R16.1
Tabular:
789 Other symptoms involving abdomen and pelvis
Excludes: symptoms referable to genital organs:
female (625.0–625.9)
male (607.0–608.9)
psychogenic (302.70–302.79)
789.2 Splenomegaly
Enlargement of spleen
Tabular:
Symptoms and signs involving the digestive system
and abdomen (R10–R19)
Excludes 1: congenital or infantile pylorospasm
(Q40.0) gastrointestinal hemorrhage (K92.0–K92.2)
intestinal obstruction (K56.-)
newborn gastrointestinal hemorrhage (P54.0–P54.3)
newborn intestinal obstruction (P76.-)
pylorospasm (K31.3)
signs and symptoms involving the urinary system
(R30–R39)
symptoms referable to female genital organs (N94.-)
symptoms referable to male genital organs male
(N48–N50)
R16 Hepatomegaly and splenomegaly, not elsewhere
classified
R16.1 Splenomegaly, not elsewhere classified
Splenomegaly NOS
Code Comparisons
Excludes
Excludes 1
 An Excludes note under a code indicates that the
 A type 1 Excludes note is a pure excludes––it means
terms excluded from the code are to be coded
"not coded here"
elsewhere. In some cases, the codes for the
 An Excludes 1 note indicates that the code excluded
excluded terms should not be used in conjunction
should never be used at the same time as the code
with the code from which it is excluded. An
above the Excludes 1 note
example of this is a congenital condition excluded
 An Excludes 1 is used for when two conditions cannot
from an acquired form of the same condition. The
occur together, such as a congenital form versus an
congenital and acquired codes should not be used
acquired form of the same condition
together. In other cases, the excluded terms may
 Only one code is needed to represent all of the detail
be used together with an excluded code. An
concerning this condition
example of this is when fractures of different bones  Combination codes are common in ICD-10-CM
are coded to different codes. Both codes may be
used together if both types of fractures are present.
Documentation Needed
 Pathological tissue diagnosis confirmation by
 Pathological tissue diagnosis confirmation by
physician is needed for more specificity for
physician is needed for more specificity for definitive
definitive diagnosis coding
diagnosis coding
ICD-9-CM
ICD-10-PCS
Procedure Code(s) Assigned
41.5
Splenectomy
07TP4ZZ
0: Medical and surgical section (procedure type)
7: Lymphatic and hemic systems (body system)
T: Resection (root operation)
P: Spleen (body part)
4: Percutaneous endoscopic (approach)
Z: None (device)
Z: None (qualifier)
Index and Tabular Volumes
Alphabetic Index:
Alphabetic Index:
Splenectomy (complete)(total) 41.5
Splenectomy
– see Resection, Lymphatic and Hemic Systems 07T
Resection
Spleen 07TP
Tabular:
41.5 Total splenectomy
Splenectomy NOS
Code also any application or administration of an
adhesion barrier substance (99.77)
Tabular (Tables):
Reference the table for 07T (see the Excerpt from ICD-10PCS Tables) to look up the remaining characters of the
code. In this case the specific body part is the spleen (P),
the approach is percutaneous endoscopic (4), and there is
no device or qualifier (Z).

Code Comparisons
Procedure code does not reflect the laparoscopic
 Complete procedure captured in one code including
approach to performing the procedure
laparoscopic approach

Documentation Needed
Extent of procedure—namely, partial or total
 Extent of procedure—namely, partial or total
 Approach
Excerpt from ICD-10-PCS Tables
0: Medical and Surgical
7: Lymphatic and Hemic Systems
T: Resection
Cutting out or off, without replacement, all of a body part
Body System
Approach
Device
Qualifier
Character 4
Character 5
Character 6
Character 7
0
1
2
3
4
5
6
7
8
9
B
C
D
F
G
H
J
K
L
M
P
Lymphatic, Head
Lymphatic, Right Neck
Lymphatic, Left Neck
Lymphatic, Right Upper
Extremity
Lymphatic, Left Upper
Extremity
Lymphatic, Right Axillary
Lymphatic, Left Axillary
Lymphatic, Thorax
Lymphatic, Internal Mammary
Right
Lymphatic, Internal Mammary
Left
Lymphatic, Mesenteric
Lymphatic, Pelvis
Lymphatic, Aortic
Lymphatic, Right Lower
Extremity
Lymphatic, Left Lower
Extremity
Lymphatic, Right Inguinal
Lymphatic, Left Inguinal
Thoracic Duct
Cisterna Chyli
Thymus
Spleen
0
4
Open
Percutaneous
Endoscopic
Z
No Device
Z
No Qualifier
48. Open fracture reduction, right tibia
ICD-9-CM
ICD-10-PCS
Code(s) Assigned
79.26 Open reduction of fracture of the tibia without
0QSG0ZZ
internal fixation
0 Medical and surgical section (procedure type)
Q Lower bones (body system)
S Reposition (root operation)
G Tibia, right (body part)
0 Open (approach)
Z None (device)
Z None (qualifier)
Index and Tabular Volumes
Alphabetic Index:
Alphabetic Index:
Reduction
Reduction
fracture
Fracture see Reposition
tibia
open 79.26
Reposition
Tibia
Right 0QSG
Tabular:
79 Reduction of fracture and dislocation
The following fourth-digit subclassification is for
use with appropriate categories in section 79 to
identify the site:
0 unspecified site
1 humerus
2 radius and ulna
3 carpals and metacarpals
4 phalanges of hand
5 femur
6 tibia and fibula
7 tarsals and metatarsals
8 phalanges of foot
9 other specified sites



Tabular (Tables):
Reference the table for 0QS (see the Excerpt from
ICD-10-PCS Tables) to look up the remaining
characters of the code. In this case the specific
body part is the right tibia (G), the approach is open
(0), and there is no device or qualifier (Z).
79.2 Open reduction of fracture without
internal fixation
Code Comparisons
One category for reduction of fracture and
 Reduction is not a root operation; reposition is
dislocation
the root operation
Third digit differentiates whether closed versus
 ICD-10-PCS has different body systems for
open reduction and whether with or without
upper and lower bones
internal fixation
 Fourth character of code specifies site of
Fourth digit specifies site of reduction
reduction including laterality
 Fifth character of code specifies approach
 Sixth character of code specifies device such as
external fixation device, internal fixation device
or none



Documentation Needed
Site of reduction
 Site of reduction, including laterality
Whether or not there is internal fixation
 Approach used to perform procedure
Whether the reduction is open or closed
 Any device that remains after the procedure is
completed
Excerpt from ICD-10-PCS Tables
0: Medical and Surgical
Q: Lower Bones
S: Reposition
Moving to its normal location or other suitable location all or a portion of a
body part
Body System
Approach
Device
Qualifier
Character 4
Character 5
Character 6
Character 7
6
7
8
9
B
C
G
H
J
K
Upper Femur, Right
Upper Femur, Left
Femoral Shaft, Right
Femoral Shaft, Left
Lower Femur, Right
Lower Femur, Left
Tibia, Right
Tibia, Left
Fibula, Right
Fibula, Left
0
3
4
Open
Percutaneous
Percutaneous
Endoscopic
4
6
Z
Internal Fixation Device
Intramedullary Fixation
Device
No Device
Z
No Qualifier
49. Percutaneous thoracic kyphoplasty
ICD-9-CM
81.66 Kyphoplasty
Alphabetic Index:
Kyphoplasty 81.66
Tabular:
81.6 Other procedures on spine
81.66 Percutaneous vertebral
augmentation
Arcuplasty
Kyphoplasty
SKyphoplasty
Spinoplasty
ICD-10-PCS
Code(s) Assigned
0PS43ZZ
0 Medical and surgical section (procedure type)
P Upper bones (body system)
S Reposition (root operation)
4 Thoracic vertebra (body part)
3 Percutaneous (approach)
Z None (device)
Z None (qualifier)
Indexed and Tabular Volumes
Alphabetic Index:
Reposition
by Body Part
Vertebra
Thoracic 0PS4
Tabular (Tables):
Reference to the table for 0PS (see the Excerpt
from ICD-10-PCS Tables) to look up the remaining
characters of the code. In this case the specific
body part is thoracic vertebra (4), the approach is
percutaneous (3), and there is no device or qualifier
(Z).
Code Comparisons
One code category
 The Alphabetic Index does not contain a main
term for Kyphoplasty
 Fourth digit indicates insertion of device to a
cavity for two different type of filler
 Kyphoplasty is a procedure where the original
 No differentiation for the operative approach
height and angle of the vertebra is restored
 Root operation for kyphoplasty is reposition
 Differentiation for the operative approach
 Differentiation for site of vertebra where the
kyphoplasty is performed
Documentation Needed
 Kyphoplasty not fusion
 Documentation of restoration of the vertebrae
 The region of the spinal column
 Type of approach
 Type of fixation device
Excerpt from ICD-10-PCS Tables
0: Medical and Surgical
P: Upper Bones
S: Reposition
Moving to its normal location or other suitable location all or a portion of a
body part
Body System
Approach
Device
Qualifier
Character 4
Character 5
Character 6
Character 7
0
1
2
3
4
5
6
7
8
9
B
0
1
2
3
4
5
6
7
8
9
B
Sternum
Rib, Right
Rib, Left
Cervical Vertebra
Thoracic Vertebra
Scapula, Right
Scapula, Left
Glenoid Cavity, Right
Glenoid Cavity, Left
Clavicle, Right
Clavicle, Left
Sternum
Rib, Right
Rib, Left
Cervical Vertebra
Thoracic Vertebra
Scapula, Right
Scapula, Left
Glenoid Cavity, Right
Glenoid Cavity, Left
Clavicle, Right
Clavicle, Left
0
3
4
Open
Percutaneous
Percutaneous
Endoscopic
X External
4
Z
Internal Fixation Device
No Device
Z No Device
Z
No Qualifier
Z No Qualifier
Updates to Part 2 Questions: Basic ICD‐9‐CM to ICD‐10‐CM and ICD‐10‐PCS Coding Exercises 36.
Classical Hodgkin disease of intrathoracic lymph nodes
Code(s): _________________________________
55.
Acute myeloblastic leukemia, in relapse
Code(s): _________________________________
70.
Posttransfusion thrombocytopenia following massive blood transfusions of whole blood
Code(s): _________________________________
80.
Type I diabetes mellitus with diabetic nephropathy
Code(s): _________________________________
84.
Type I diabetes mellitus , out of control
Code(s): _________________________________
90.
Hurler’s syndrome, Scheie’s syndrome, and Sanfilippo’s syndrome are all forms of
_________________________________.
208.
Pressure ulcer of right heel, stage 2
Code(s): _________________________________
212.
Abscess of left axilla
256.
Code(s): _________________________________
Inlet contraction of pelvis with obstruction, single liveborn infant delivered vaginally
Code(s): _________________________________
359.
Well-baby visit for 20-day-old infant
Code(s): _________________________________
394.
Posterior spinal fusion of the posterior column at L2-L4 with Bak cage interbody fusion
device, open
Code(s): _________________________________
Updates to Part 2 Solutions: Solutions to Basic ICD‐9‐CM to ICD‐10‐CM and ICD‐10‐PCS Coding Exercises 36.
C81.72
Rationale: The Alphabetic Index main term is Hodgkin disease which has a cross
reference note to see Lymphoma, Hodgkin. Following this cross reference note the
main term is Lymphoma, subterms Hodgkin, classical resulting in C81.7. Review of this
subcategory in the Tabular reveals that the fifth character of 2 is required for the
intrathoracic lymph nodes resulting in code C81.72.
53.
C83.73
Rationale: The Alphabetic Index, main term Lymphoma, subterm Burkitt results in
C83.7-. The Alphabetic Index main term Burkitt, subterm lymphoma also results in
C83.7-. Review of the Tabular indicates that C83.73 is the correct code for Burkitt’s
lymphoma of the intra-abdominal lymph nodes.
54.
C90.01
Rationale: Following treatment, this disease may go into remission, where the patient is
not considered cancer free, but is managing the disease or is symptom free. For coding,
the Alphabetic Index main term Myeloma, subterm in remission is reviewed. Note the
nonessential modifier “multiple” and the code C90.01. A fifth digit is required to indicate
whether or not the patient is in remission. In this case, 1 is assigned to reflect that
status. If not mentioned in the documentation, 0 would be used. When in doubt, the
physician should always be consulted to determine the correct code.
55.
C92.02
Rationale: The Alphabetic Index main term is Leukemia, subterm acute myeloblastic
resulting in C92.0-. Review of the Tabular indicates that C92.02 is the correct code for
acute myeloblastic leukemia in relapse.
67.
D64.89
Rationale: The Alphabetic Index main term is Anemia, subterm osteosclerotic, or
Osteosclerotic anemia, to assign code D64.89. Note that this type of anemia classifies
to other specified anemias.
70.
D69.51
Rationale: The Alphabetic Index main term is Thrombocytopenia, subterms due to,
massive blood transfusion, resulting in code D69.59. Review of the Tabular reveals that
the correct code is D69.51 not D69.59.
80.
E10.21
Rationale: The Alphabetic Index main term is diabetes, subterms type 1, with,
nephropathy, resulting in code E10.21. ICD-10-CM provides combination codes that
include both the underlying condition (diabetes) and the manifestation (nephropathy).
ICD-10-CM does not differentiate whether or not the diabetes is out of control.
84.
E10.65
Rationale: The Alphabetic Index main term is Diabetes, subterm out of control with
cross reference note to Code to diabetes, by type, with hyperglycemia. Following the
cross reference note the main term is Diabetes, subterms type 1, with hyperglycemia
resulting in code E10.65.
90.
Mucopolysaccharidosis
Rationale: The code for Hurler’s syndrome is E76.02, Scheie’s syndrome is E76.03, and
Sanfilippo’s syndrome is E76.22. Upon review of the Tabular List all three of these
syndromes are a type of mucopolysaccharidosis.
96.
b. Two codes
Rationale: Two ICD-10-CM codes are required. The Alphabetic Index main term is
Creutzfeldt-Jacob disease or syndrome with a code from subcategory A81.0 being
assigned. In the Tabular there is a note under category A81.0 which states “Use
additional code to identify: dementia with behavioral disturbance (F02.81), dementia
without behavioral disturbance (F02.80)”.
151.
I63.211
Rationale: The vertebral artery is a precerebral artery. The Alphabetic Index main term
is Infarction, subterms cerebral, due to, stenosis, precerebral arteries I63.2-. Review of
this subcategory in the Tabular reveals that I63.211 is the correct code for cerebral
infarction due to stenosis of the right vertebral artery.
168.
J96.10
Rationale: The Alphabetic Index main term is Failure, subterms respiration, chronic,
resulting in code J96.10.
184.
K35.80
Rationale: The main term in the Alphabetic Index is Appendicitis, subterm acute,
resulting in code K35.80. Note that obstructive is a nonessential modifier.
208.
L89.612
Rationale: The Alphabetic Index main term is Ulcer, subterms, pressure, stage 2, heel
resulting in L89.6-. Review of the Tabular List reveals that L89.612 is the correct code.
Note that this code is a combination code that specifies the site, including laterality and
the stage of the pressure ulcer.
211.
T55.1x1A, L24.0
Rationale: The Alphabetic Index main term is Dermatitis, subterms due to, detergent,
resulting in code L24.0. In the Tabular List there is a note under category L24 to code
first (T36–T65) to identify drug or substance. Review of the Drugs and Chemical Table,
substance term Detergent NEC, unintentional results in T55.1x1. In the Tabular List
there is a note under category T55 stating “the appropriate seventh character is to be
added to each code from category T55: A initial encounter, D subsequent encounter
and S sequela.” Since this is the initial encounter the seventh character of “A” is added
to the code.
256.
O65.2, Z37.1
Rationale: The main term is Delivery, subterms complicated by, obstruction, pelvic,
contraction, inlet resulting in code O65.2. The main term for the outcome of delivery
code is Outcome of Delivery, subterms single, liveborn resulting in code Z37.1.
295.
P77.9
Rationale: The Alphabetic Index main term is Enterocolitis, Subterms necrotizing, in
newborn resulting in code P77.9.
306.
R11.2
Rationale: The Alphabetic Index main term is Nausea, subterm with vomiting, resulting
in code R11.2. This code can also be accessed via main term Vomiting, subterm with
nausea.
336.
W03xxxA
Rationale: The Alphabetic Index main term is Tackle in sport, resulting in code W03 with
a seventh character of “A” for the initial encounter. (Note: In the 2007 version of ICD10-CM, the main term “Tackle in sport” is located alphabetically after the main term
“Terrorism”.)
338.
X06.2xxA, Y92.511 Y93.89, Y99.8
Rationale: The Alphabetic Index main term is Ignition, subterm clothes, clothing NEC
(from controlled fire), resulting in code X06.2 with a seventh character of “A” for initial
encounter. The main term is Place of occurrence, subterm restaurant, resulting in code
Y92.511. The Tabular List indicates that an activity code should be used in conjunction
with a place of occurrence code. To find the activity code, the main term is Activity,
resulting in code Y93.89 To find the external cause status code, the main term is
External cause status, subterm leisure activity resulting in code Y99.8.
359.
Z00.111
Rationale: The Alphabetic Index main term is Admission, subterm examination at
health care facility with a cross reference note to see also Examination. Following this
cross reference note, the main term is Examination, subterm Newborn with cross
reference note to see Newborn, examination. Following this second cross reference
note, the main term is Newborn, subterms, examination, 8 to 28 days old resulting in
code Z00.111.
375.
00160J6
Rationale: During a ventriculoperitoneostomy a shunt is placed leading from skull
cavities to the peritoneal cavity to relieve excess cerebrospinal fluid created in the
chorioid plexuses of the third and fourth ventricles of the brain. The root operation in
ICD-10-PCS for altering the route of passage of the contents of a tubular body part is
Bypass. The Alphabetic Index main term is Bypass, Cerebral Ventricle 00160.
Reference the table for 001 for the remaining characters of the code. In this instance,
the specific body part is the cerebral ventricle (6), the approach is open (0), the device
is a synthetic substitute (J), and the qualifier is the peritoneal cavity (6), resulting in code
00160J6.
378.
099770Z
Rationale: Myringotomy is a surgical procedure where a small incision is made in the
patient’s eardrum with a small tube being placed in the eardrum incision to remove fluid.
The Alphabetic Index main term is Myringotomy, “see Drainage, Ear, Nose, Sinus, 099.”
This code can also be accessed via the main term Tympanotomy. The terms
“myringotomy” and “tympanotomy” are synonymous and the physician’s choice is
usually based on the terminology used at the medical school he or she attended.
Reference the table for the remaining characters of the code. The body part is right
tympanic membrane (7), the approach is via natural or artificial opening (7), the device
is drainage device (0), and there is no qualifier (Z), resulting in code 099770Z.
379.
0Y6J0Z1
Rationale: The Alphabetic Index main term is Amputation, “see Detachment.” Following
the cross reference, the main term is Detachment, Leg, Lower, Left 0Y6J0Z. Reference
the table the remaining characters of the code. The body part is the left lower leg (J),
the approach is open (0), there is no device (Z), and the qualifier is high (1). The
qualifier high refers to the portion of the tibia and fibula closest to the knee. The code is
0Y6J0Z1.
380.
02RG08Z
Rationale: The Alphabetic Index main term is Replacement, Valve, Mitral 02RG.
Reference the table for the remaining characters of the code. The approach is open (0),
the device is zooplastic tissue (8), and there is no qualifier (Z), resulting in code
02RG08Z.
382.
02100Z9
Rationale: The Alphabetic Index main term is Bypass, Artery, Coronary, One Site 0210.
Reference the table for 021 for the remaining characters of the code. The body part
value is one site (0), the approach is open (0), there is no device (Z), and the qualifier is
the left internal mammary artery (9), resulting in code 02100Z9. With an internal
mammary graft, the vessel is sutured to the coronary artery but remains attached to its
native blood supply on the other end.
383.
07T10ZZ, 07T20ZZ
Rationale: During a radical neck dissection, all of the cervical lymph nodes are removed
from both sides of the neck. When an entire lymph node chain is removed the
appropriate root operation is resection and when a lymph node is cut out it is excision.
The Alphabetic Index main term is Resection, Lymphatic, Neck, Right 07T1 and Left
07T2. Reference the table for the remainder of the characters of the code. For the first
code, the body part is right neck lymphatic (1), the approach is open (0), and there is no
device or qualifier (Z). For the second code, the body part is left neck lymphatic (2). The
codes are 07T10ZZ and 07T20ZZ.
384.
0D5N8ZZ
Rationale: The Alphabetic Index main term is Fulguration, “see Destruction.” Following
the cross reference, the main term is Destruction, by Body Part, Colon, Sigmoid 0D5N.
Reference the table for the remaining characters of the code. The approach is via
natural or artificial opening endoscopic (8), and there is no device or qualifier (Z),
resulting in code 0D5N8ZZ.
385.
05CD0ZZ
Rationale: Extirpation is the root operation for taking or cutting out solid material from a
body part. For a thrombectomy, the thrombus is the solid material removed. The
Alphabetic Index main term is Thrombectomy see Extirpation. Following the cross
reference, the main term is Extirpation, Vein, Cephalic, Right 05CD. Reference the 05C
table for the remaining characters of the code. The body part value is the right cephalic
vein (D), the approach is open (0), and there is no device or qualifier (Z), resulting in
code 05CFD0ZZ.
387.
0TY00Z0
Rationale: The Alphabetic Index main term is Transplantation, Kidney, Right 0TY00Z.
Reference the 0TY table for the remaining characters of the code. The body part value is
the right kidney (0), the approach is open (0), the device is none (0), and the qualifier is
allogenic (0), resulting in code 0TY00Z0.
388.
01N54ZZ
Rationale: During a carpal tunnel release procedure, the transverse carpal ligament is
cut, which releases pressure on the median nerve. The Alphabetic Index main term is
Release, by Body Part, Nerve, Median 01N5. Reference the 01N table for the remaining
characters of the code. The body part is the median nerve (5), the approach is
percutaneous endoscopic (4), and there is no device or qualifier (Z), resulting in code
01N54ZZ.
389.
0JH60P0, 02HK3MA
Rationale: For insertion of the pacemaker generator, the Alphabetic Index main term is
Insertion of device in, Subcutaneous Tissue and Fascia, Chest, Pacemaker, Single
Chamber 0JH6. Reference the 0JH table for the remaining characters of the code. The
body part value is subcutaneous tissue and fascia, chest (6), the approach is open (0),
the device is pacemaker (P), and the qualifier is single chamber pacemaker (0),
resulting in code 0JH60P0. For insertion of the lead, the main term is Insertion of device
in, Ventricle, Right 02HK. Reference the 02H table for the remaining characters of the
code. The body part is right ventricle (K), the approach is percutaneous (3), the device
is a cardiac lead (M), and the qualifier is pacemaker lead (A).
390.
0QSK04Z
Rationale: The root operation for a fracture reduction is reposition. Reposition is the
moving of a body part from an abnormal location to its normal location. The Alphabetic
Index main term is Reduction, Fracture see Reposition. Following the cross reference,
the main term is Reposition, Fibula, Left 0QSK. Reference the 0QS table for the
remaining characters of the code. The body part value left fibula (K), the approach is
open (0), the device is internal fixation device (4), and the qualifier is none (Z), resulting
in code 0QSK04Z.
391.
0SR90J7
Rationale: The Alphabetic Index main term is Replacement, Joint, Hip, Right 0SR9.
Surgeons also use the term “total hip arthroplasty” and the code may also be accessed
via the main term Arthroplasty, “see Replacement, Lower Joints 0SR.” Reference the
table 0SR for the remaining characters of the code. The body part value is right hip joint
(9), the approach is open (0), the device is synthetic substitute (J), and the qualifier is
ceramic-on-ceramic (7), resulting in code 0SR90J7.
392.
0XM90ZZ
Rationale: The Alphabetic Index main term is Reattachment, by Body Part, Arm, Upper
0XM. Reference the table for 0XM for the remaining characters of the code. The body
part value is the left upper arm (9), the approach is open (0), and there is no device or
qualifier (Z), resulting in code 0XM90ZZ.
394.
0SG1031
Rationale: The Alphabetic Index main term Fusion, Lumbar Vertebra, 2 or more 0SG1.
Reference the table 0SG for the remaining characters of the code. The body part value
is lumbar vertebral joints 2 or more (1), the approach is open (0), the device is an
interbody fusion device (3), and the qualifier is posterior approach, posterior column (1),
resulting in code 0SG1031.
395.
0SJC4ZZ
Rationale: The Alphabetic Index main term is Arthroscopy, “see Inspection, Lower Joints
0SJ.” The main term is Inspection, , Joint, Knee, Right 0SJC. Reference the table 0SJ for
the remaining characters of the code. The body part value is the right knee joint (C), the
approach is percutaneous endoscopic (4), and there is no device or qualifier (Z), resulting
in code 0SJC4ZZ
396.
0SWD0JZ
Rationale: The Alphabetic Index main term is Revision of device in, Joint, Knee, Left
0SWD. Reference the table 0SW for the remaining characters of the code. The body
part value is the left knee (D), the approach is open (0), the device is a synthetic
substitute (J), and there is no qualifier (Z), resulting in code 0SWD0JZ.
397.
0DB98ZX
Rationale: The Alphabetic Index main term is Biopsy, “see Excision.” Following the
cross reference, the main term is Excision, by Body Part, Duodenum 0DB9. Reference
the table 0DB for the remaining characters of the code. The body part value is the
duodenum (9), the approach is via natural or artificial opening endoscopic (8), there is
no device (Z), and the qualifier is diagnostic (X), resulting in code 0DB98ZX.
398.
0UT9FZZ, 0UTC4ZZ
Rationale: During a laparoscopic-assisted total vaginal hysterectomy the uterus and
cervix are resected. ICD-10-PCS has distinct body part values for both the uterus and
cervix therefore two codes are required to completely code this procedure. The
Alphabetic Index main term is Hysterectomy, “see Resection, Uterus 0UT9.” Reference
the table 0UT for the remaining characters of the first code. The body part value is the
uterus (9), the approach is via natural or artificial opening with percutaneous endoscopic
assistance (F), and there is no device or qualifier (Z), resulting in code 0UT9FZZ. For
resection of the cervix, the main term is Resection, Cervix 0UTC. Reference the table
0UT for the remaining characters of the second code. The body part value is the cervix
(C), the approach is percutaneous endoscopic (4) and there is no device or qualifier (Z),
resulting in code 0UTC4ZZ.
399.
0UDB8ZX
Rationale: The root operation of extraction is defined as pulling or stripping out or off all
or a portion of a body part. During a D&C a curette is used to scrape the lining of the
uterus. The Alphabetic Index main term is Extraction, Endometrium 0UDB. Reference
the table 0UD for the remaining characters of the code. The body part value is the
endometrium (B), the approach is via natural or artificial opening endoscopic (8), the
device is none (Z), and the qualifier is diagnostic (X), resulting in code 0UDB8ZX.
400.
0TF6XZZ
Rationale: Following the cross reference for Lithotripsy, the main term is Fragmentation,
Ureter, Right 0TF6. Reference the table 0TF for the remaining characters of the code.
The body part value is the right ureter (6), the approach is external (X), and there is no
device of qualifier (Z), resulting in code 0TF6XZZ.