Blog

It is appropriate to assign some procedure code based on documentation by the nonphysician professional who provided the service. 

A patient was admitted for cholecystectomy because of chronic cholecystitis. Before she went to the operating room the next morning, nursing personnel noted that she had apparently developed a urinary tract infection, and laboratory tests confirmed a diagnosis of urinary tract infection due to E. coli. Because of the infection, the surgery was canceled, antibiotic therapy was instituted, and the patient was discharged on the third hospital day to continue antibiotic therapy at home. She will be seen in the physician’s office in three weeks, and surgery will be rescheduled. Hints: Remember the reason for the admission is the principal diagnosis.  You will have a total of 4 codes to assign- the principal diagnosis followed by 3 additional codes.  Remember to use the decimal point and capital letters.   There are no procedure codes. 1. [BLANK-1] 2. [BLANK-2] 3. [BLANK-3] 4. [BLANK-4]

Which of the following root operations is defined as “cutting off all or a portion of the upper or lower extremeties”? 

Root operations in the Placement Section include only those procedures that are performed without making an incision or a puncture.

The coding professional must be sure that the medical record documentation supports code assignment.

Which of the following is the main purpose of the ICD-10-PCS Alphabetic Index? 

Words such as “with,” “in,” “due to,” and “associated with” are used to express the relationship between the main term or a subterm and an associated condition or etiology.

Components of a procedure specified in the root operation definition and explanation are not coded separately. 

A patient is admitted for an intended cholecystectomy with exploration of the common duct. However, upon entering the abdominal cavity (peritoneal cavity) metastatic malignancy involving stomach and duodenum, with possible primary site in pancreas, necessitated canceling the intended procedure and closing the operative wound. Assign the appropriate procedure code(s) for the encounter. Hint: Code to the extent that the procedure was performed [BLANK-1]

Which of the following terms refers to either a reduction in the quantity of hemoglobin or a reduction in the volume of red blood cells?