Advanced PCS Coding for
Tubular Body Parts
Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA
Kuehn Consulting, LLC
Waukesha, WI
(262) 574-1064 or (414) 807-4589
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Today’s Discussion
•
•
•
•
•
•
•
•
Quick Review
Anatomical Regions, General
Gastrointestinal System
Genitourinary System
Cardiovascular and Lymphatic Systems
Respiratory System
Device “Show and Tell”
Questions and Answers
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All About You…
Level of knowledge of ICD-10-PCS:
A. Know what it is
B. Have been to some introductory
programs
C. Can code in the new system
D. Can code with proficiency
E. I’m an approved trainer
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ICD-10-PCS Code Structure
1
2
3
4
Root
Operation
Section
Body
System
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6
Approach
Body Part
7
Qualifier
Device
4
Building a Code
• Index provides first 3 characters of
code, associated with a code table
• Table is referenced to build the last 4
characters of the code
• Table arranged in rows to allow only
valid character combinations
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ICD-10-PCS Tables
Each table contains four columns and
a varying numbers of rows
Column: Specifies the allowable values for
characters 4 through 7
Row:
Specifies the valid combinations
of values
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System Structure
Step 1 - Alphabetic Index
Step 2 - PCS Tables
•
•
•
•
•
Uses root operations as main entries
Contains references for
– Devices
– Body Parts
Guides you to the correct table
Open appendectomy (Resection):
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Final coding decision = 0DTJ0ZZ
0 Section = Medical and Surgical
D Body System = Gastrointestinal System
T Resection = Cutting out or off, without replacement, all of a body part
Body Part
Approach
Device
Qualifier
1
2
3
4
Esophagus, Upper
Esophagus, Middle
Esophagus, Lower
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
0 Open
4 Percutaneous
Endoscopic
7 Via Natural or
Artificial
Opening
8 Via Natural or
Artificial
Opening
Endoscopic
Z No Device
Z No Qualifier
Building a Code = 0DTJ0ZZ
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Section – Character 1
• Defines the
general type of
procedure
• In the Medical
and Surgical
Section, the first
character is
always the
number “0”
Section
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Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
9
Body System – Character 2
• Defines the general physiological system
on which the procedure is performed, or
anatomical region where the procedure is
performed
• Some traditional categories are subdivided
into several body systems.
Cardiovascular is subdivided into five body systems:
Heart and Great Vessels
Upper Veins
Upper Arteries
Lower Veins
Lower Arteries
Section
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Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
10
Root Operations
Alteration
Bypass
Change
Control
Creation
Destruction
Detachment
Dilation
Division
Drainage
Excision
Extirpation
Extraction
Fragmentation
Fusion
Insertion
Inspection
Map
Occlusion
Reattachment
Release
Section
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Body
System
Removal
Repair
Replacement
Reposition
Resection
Restriction
Revision
Supplement
Transfer
Transplantation
Root
Operation
Body Part
Approach
Device
Qualifier
11
Body Part – Character 4
• Defines the specific anatomical site
where the procedure is performed
• 34 possible body part values in each
body system
24 usable letters (no I or O) and 10
numbers
Section
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Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
12
Index Contents
• Main terms in the Index are:
– Root operation names
– Common surgical terms such as
• Appendectomy
– See Excision, Appendix 0DBJ
– See Resection, Appendix 0DTJ
– Cross-references for body part names
• Vermiform appendix
– Use Appendix
– Cross-references for devices
• Physiomesh™
– Use Synthetic Substitute
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Index by Body Part?
• Medial meniscus
– Use Joint, Knee, Right
– Use Joint, Knee, Left
• It means that PCS refers to the medial
meniscus as the Joint, Knee, right or left
• Access index using root operation name
and then select Joint, Knee
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Approach – Character 5
• Defines the technique used to reach
the site of the procedure
• 7 different approach values:
–
–
–
–
–
–
Open
Percutaneous
Percutaneous Endoscopic
Via Natural or Artificial Opening
Via Natural or Artificial Opening Endoscopic
Via Natural or Artificial Opening with percutaneous
endoscopic assistance
– External
Body
Root
Section
Body Part
Approach
Device
System
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Operation
Qualifier
15
Device – Character 6
• The term “device” includes only devices
that remain after the procedure is
completed
– Instruments for visualization are specified
in the approach character
• Materials incidental to a procedure such as
clips and sutures are not considered
devices
Section
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Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
16
Qualifier – Character 7
• Defines an additional attribute of the
procedure performed, if applicable
• May be specific to a root operation, body
system, or body part
• Examples:
– Type of transplant
– Second site for a bypass
– Diagnostic excision (biopsy)
Section
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Body
System
Root
Operation
Body Part
Approach
Device
Qualifier
17
Tubular Body Parts
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Anatomical Regions,
General
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Anatomical Regions Body Parts
•
•
•
•
•
•
•
•
Head
Neck
Face
Upper and lower jaw
Oral cavity and throat
Chest wall
Abdominal wall
Pleural cavity, right
and left
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•
•
•
•
•
•
•
•
Mediastinum
Pericardial cavity
Abdominal cavity
Peritoneal cavity
Retroperitoneal cavity
Pelvic cavity
Upper and lower back
Perineum, male and
female
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What’s Coded Here?
• Procedures performed on:
– Body cavities
•Inspection of peritoneal cavity
– Large surface areas
•Repair of abdominal wall
– Entire tubular tracts
•Inspection of entire gastrointestinal
tract
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Gastrointestinal and
Hepatobiliary Systems
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Gastrointestinal System
• Mechanical digestion of food by chewing
• Chemical digestion by saliva and chemicals
in the stomach and from the liver
• Mixing and propelling food (peristalsis)
from pharynx through large intestines
• Absorption of nutrients and water by small
intestines and water by large intestines
• Elimination of indigestible waste products
as defecation
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Gastrointestinal System
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Hepatobiliary System
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Anastomosis Following
Resection
Not coded
separately
because the
normal route
was
reconnected
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Let’s Code – Case 1
The patient was diagnosed with
diverticulosis and had a complete
removal of the descending colon along
with a removal of the proximal section
of the sigmoid colon using an open
approach.
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Case 1
• Root operation: Resection
• Code: 0DTM0ZZ
Body
System
Root
Operation
Medical and
Surgical
Gastrointestinal
System
0
D
Section
Body Part
Approach
Device
Qualifier
Resection
Descending
Colon
Open
No Device
No
Qualifier
T
M
0
Z
Z
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Case 1
• Root operation: Excision
• Code: 0DBN0ZZ
Body
System
Root
Operation
Medical and
Surgical
Gastrointestinal
System
0
D
Section
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Body Part
Approach
Device
Qualifier
Excision
Sigmoid
Colon
Open
No Device
No
Qualifier
B
N
0
Z
Z
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What is this called?
?______________
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Left Hemicolectomy
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Right Hemicolectomy
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Bypass
• Bariatric procedures
– Roux-en-Y
• Anastomosis in unusual
configurations
– Billroth II
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Bypass
Non-Coronary
Body Part
Qualifier
From
To
(Downstream
Location)
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36
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Colostomy versus Ileostomy
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Ileal Reservoir Options
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Ostomy Take-Down
• Internal structure repair, plus
• Abdominal wall repair
– Qualifier = Stoma
• Where do bypasses start?
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Let’s Code – Case 2
Several months post-op and
after the colon is healed,
the patient’s colostomy is
taken down. During the
original surgery, the
sigmoid colon was entirely
removed.
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Nissen Fundoplication
Root operation =
Restriction
Body part =
Esophagogastric junction
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GI Stents
Self-Expandable
Metal Stent (SEM)
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Gastric Neurostimulator
• Gastric neurostimulator
for gastroparesis
(delayed gastric
emptying)
– “Functional unit” generator
– “Delivery mechanism”
– lead(s)
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Let’s Code – Case 3
A patient with gastroparesis that
is resistant to medication has a
gastric stimulator placed. One
lead is placed on the surface of
the stomach and the generator is
placed into a subcutaneous
pocket in the abdomen.
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Reference Manual - Dilation
• Definition: Expanding an orifice or
the lumen of a tubular body part
• Explanation: The orifice can be a
natural orifice or an artificially
created orifice. Accomplished by
stretching a tubular body part using
intraluminal pressure or by cutting
part of the orifice or wall of the
tubular body part
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Let’s Code – Case 4
A 2-week-old infant is
diagnosed with pyloric
stenosis and the surgeon
performs a laparoscopic
pyloromyotomy to cure
the problem.
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Genitourinary System
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Genitourinary System
• Urinary System
–
–
–
–
Removes waste from blood stream
Regulates fluid volume of the body
Maintains electrolyte concentration and pH levels
Secrete erythropoietin and rennin
• Reproductive Systems
– Male and Female:
• Produce and transport gamete cells
• Produce hormones
– Female: Nurture developing offspring
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Urinary System
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Ureteral Stents
• Stents hold
open the ureter
(go around stones
or other
constricted area)
to allow urine
to pass
• Catheters drain
urine from the
body (held in
place by an
inflated balloon)
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Let’s Code – Case 5
The patient was
diagnosed with a left
ureteral stone and
underwent cystoscopic
extraction of the stone
and placement of a stent
into the left ureter.
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Let’s Code – Case 6
• The patient is taken
to the OR for
retrieval of a ureteral
stent from the left
ureter and a
cystoscopy.
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Ileal Conduit
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Let’s Code – Case 7
The surgeon makes a midline
incision and performs a
complete cystectomy. The
surgeon creates a neobladder
for the patient using a
harvested piece of ileum. The
neobladder connects the
ureters to the outside.
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Percutaneous Drainage
Used for
percutaneous
placement of a
malecot flower
catheter in the
renal pelvis for
nephrostomy
drainage.
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Not a urinary catheter
57
Urethromeatoplasty
• A urethromeatoplasty moves the position
of the urethra, when the opening is
coronal.
– Root operation is Reposition
• If the opening is in the shaft, there is no
urethra present and a replacement is
needed.
– Root operation is Replacement
• Both conditions are called hypospadias and
the surgeon may call it a repair.
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Urethromeatoplasty
• Picture A shows the meatus on
the underside of the penis
• Pictures B through D show the
incision of the glans penis and
the repositioning of the
meatus to the tip of the penis
• Pictures E and F show the
closure
• Coded to the root operation
Reposition
• Body part value is the urethra
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Let’s Code – Case 8
A 1-year-old male is
taken to the OR for
an open correction of
his coronal
hypospadias.
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Occlusion
Male
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Female
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Hysterectomy
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Let’s Code – Case 9
A Pfannenstiel incision is made in the
patient’s abdomen and the
peritoneum is entered. The uterine
supporting structures are divided. A
circumferential incision is made
around the cervix and the uterus,
cervix, tubes and ovaries are
delivered through the incision.
Hemostasis was achieved and the
abdominal incision is closed in layers.
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Suspension With a Device
Mid urethral sling procedure
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Suspension Without a Device
Uterosacral Ligament
Fixation:
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Sacrospinous Vault
Fixation:
Auditing
Procedure: Uterine fibroid
embolization, left side
Code assigned: 04LF3DU
Is this correct?
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Circulatory and Lymphatic
Systems
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Circulatory and Lymphatic
Systems
• Circulates the blood to the lungs for
oxygenation and throughout the
body
• Eliminates waste products from cells
• Lymphatic system:
– Returns interstitial fluid to the blood
– Absorbs fat and fat-soluable vitamins
– Provides defense against disease
– Similar in consistency to blood plasma
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The Heart
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Cardiac Conduction Mechanism
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Coronary Arteries
• PCS uses the number of sites treated
– Not the names of the arteries
– Not the number of arteries treated
• Code the number of sites treated
using the same approach, device and
qualifier
• If anything is different, assign a
separate code
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Coronary Arteries
(descending)
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Bypass
Coronary Arteries
Body Part
Qualifier
Number
of Sites
Treated
From
(Blood
Source)
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021 Table
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Coronary Artery Bypass Grafting
• CABG (Bypass)
• Free Vein Graft:
– Greater Saphenous
Vein
• Free Artery Grafts:
– Right Internal
Mammary
– Radial Artery
• Pedicle Artery Graft:
– Left Internal
Mammary artery
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Bypass
Non-Coronary
Body Part
Qualifier
From
To
(Downstream
Location)
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Axillo-Femoral Bypass
Femoral-Femoral component
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Let’s Code – Case 10
Left internal mammary artery
bypass to the diagonal artery
and the left anterior
descending artery
Left greater saphenous free
graft to the right marginal
artery
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Case 10
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AV Fistula and AV Graft
Device
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Let’s Code – Case 11
The surgeon places a synthetic
AV graft between the brachial
artery and the basilic vein in
the patient’s right forearm.
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“Un-doing an AV Fistula or Graft”
• AV fistulas are repaired
– Repair the arterial side
– If described, occlude the venous side or
repair the venous side
• AV grafts are a device
– Remove the device from the arterial
side
– Remove the device from the venous
side
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Heart Valves
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Cardiac Valve Replacement
• Biologic vs.
Mechanical
–
–
–
–
Replacement
Aortic Valve
Tricuspid Valve
Mitral Valve
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Transcatheter Aortic Valve Replacement
(TAVR)
http://www.youtube.com/watch?v=csxJYTLXNJY
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Let’s Code – Case 12
The patient undergoes a
TAVR using a device
that is a combination of
Porcine tissue and
synthetic substitute.
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Ventricular Septal Defect
• Closed via an
open
approach
• Synthetic
material sewn
in as a patch
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REPAIRING ANEURYSMS
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Aneurysm Repair
• Open Surgical
• Root operation =
• Supplement
• Endovascular
restriction with a
covered stent using
intraluminal device
• Root operation =
• Restriction
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Extraluminal Restriction
Aneurysm Clipping
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Intraluminal Restriction
Endovascular Coil
placement
Root operation =
Restriction
Device =
Intraluminal
device
Percutaneous Coiling
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Endovascular Repair of
Abdominal Aortic Aneurysm
• Intraluminal
device
• Bifurcated
prosthesis
• Root operation =
• Restriction
• Device =
• Intraluminal
device
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Let’s Code – Case 13
The patient undergoes an
endovascular repair of an
infrarenal abdominal
aortic aneurysm using a
covered stent with limbs
placed into the common
iliac arteries.
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Pacemaker
• Medical device that delivers
electrical impulses to the
heart muscles using
electrodes
• Regulates the beating of the
heart
• Maintains an adequate heart
rate when:
– Heart too slow
– Block in conduction
mechanism
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Defibrillator
• An implantable cardioverterdefibrillator (ICD) is a small
battery-powered electrical
impulse generator:
– Patient at risk for sudden
cardiac death due to:
• Ventricular fibrillation
• Ventricular tachycardia
• Programmed to detect cardiac
arrhythmia and correct it by
delivering a jolt of electricity
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Cardiac Resynchronization
Therapy
• “Biventricular Pacing” -
CRT uses a specialized
pacemaker to re-coordinate the action of the right and left
ventricles in patients with heart failure.
• Treats heart failure and dilated
cardiomyopathy
• Pacemaker Pulse Generator
– Stratos LV, LV-T
• Defibrillator Pulse Generator
– Cognis CRT-D, Contak Renewal 3 RF CRT-D
– Livian CRT-D, Ovatio CRT-D
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Let’s Code – Case 14
The surgeon places a
pacemaker-defibrillator
generator into a subcutaneous
pocket in the patient’s chest
and threads the leads into the
right atrium and right
ventricle.
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VENOUS ACCESS DEVICES
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Perm-A-Cath
Tunneled Central Venous Catheter
Insertion, Infusion Device PLUS
Insertion, Vascular Access
Device in SubQ of Chest
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PICC or Central Venous
Catheter
Insertion,
Heart and great vessels,
infusion device
100
Vascular Access Port,
Reservoir and Pump
Implantable Vascular
Access Device
Implantable VAD,
Reservoir and Pump
Port-A-Cath
Insertion, SubQ,
Vascular access device
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Insertion, SubQ, Vascular
Access Reservoir PLUS
Infusion device, pump
101
Let’s Code – Case 15
In preparation for upcoming
chemotherapy, the surgeon places
an infusion device percutaneously
into the patient’s superior vena cava
and places an indwelling port into a
subcutaneous pocket in the
patient’s right chest via incision,
connecting it to the infusion device.
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Auditing
Procedure: Bone marrow biopsy of
the sternum
Code assigned: 079T3ZX
Is this correct?
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Respiratory System
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Respiratory System
• Manages the breathing and
respiratory process
• Works with Circulatory system to:
– Deliver oxygen to cells
– Remove waste products of metabolism
• Shares mouth and throat with the
Gastrointestinal system
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Temporary Airways
Endotracheal Airway
Nasopharyngeal
Airway (NPA) or
Nasal Trumpet
(Integral to mechanical ventilation)
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More “Permanent” Airway
Tracheostomy
• Root Operation
– Bypass
• Qualifier
– Cutaneous
Approach is typically
percutaneous in ER and
open when taken to OR
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Let’s Code – Case 16
The patient is taken to the
OR. A tracheostomy is
created and a
tracheostomy device is
inserted.
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Bronchoscopy Versus VATS
Via Natural or Artificial
Opening Endoscopic
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Percutaneous Endoscopic
(VATS)
109
Let’s Code – Case 17
The patient is taken to the
OR where the tracheostomy
opening is explored. The
tracheostomy device is
removed. Excess scar tissue
is excised from the opening
and a new tracheostomy
device is placed.
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Bronchial Devices
• Endobronchial Stents
– Malignant disease
– Esophageal varices that
intrude through tracheal
wall
– Recurrent tracheal fibromas
• Root operation =
Dilation
• Device =
Intraluminal Device
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Bronchial Devices
• Endobronchial Valves
– One way valves
– No air distally
– Allows mucous
proximally
• Root operation
– Insertion
• Device
– Endobronchial Valve
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Herniorraphy – It’s the Hole!
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Let’s Code – Case 18
• The patient is taken to the OR for
repair of a left-sided protrusion of
the stomach up through the
diaphragm. The surgeon repairs
the hernia with implantation of a
Prolene mesh patch.
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