HIM 1126 Module 03 Coding Worksheet

Below you will find brief documentation for PCS procedures to code. Read the documentation and find the correct PCS code. Hints and tips are in bold, italic, and parenthesis.
1. A physician removes a large navy bean from a child's right nostril using forceps. The PCS code for this procedure is: 09CKXZZ.
2. Neurolysis of the right median nerve utilizing a needle through the skin. The PCS code for this procedure is:01N53ZZ.
3. A patient has a portion of the sigmoid colon removed via an open surgical procedure. The PCS code for this procedure is: _________________________.
4. A patient has a bronchoscopy for diagnostic purposes. The PCS code for this procedure is: ________________.
5. A patient had a gastroscopy done. The PCS code for this procedure is: _______________.
6. A patient had an open colostomy performed from the descending colon to the abdominal wall. The PCS code for this procedure is: ____________________________-
7. The patient had the distal portion of the right lower (inferior) parathyroid removed with an open procedure. The PCS code for this procedure is: __________________________.
8. A patient had a portion of the pancreas removed for biopsy via FNA (fine needle aspiration). The PCS procedure code for this is: ____________________.
9. A mitral valve replacement is done using a porcine valve via a sternotomy which is an open approach. The PCS code for this procedure is: ____________________.

Below you will find three case studies with examples of a typical inpatient operative report. For each case study given below, read the documentation and translate only the procedures into the correct ICD 10 PCS codes.. Make sure you understand the objective of the procedure in order to pick the correct root operation. Use all your tools and instruction given so far in the course to code these 3 case studies.

Case Study #1:
Preoperative Diagnosis: Sensorineural hearing loss.
Postoperative Diagnosis: Sensorineural hearing loss.
Procedure: Right cochlear implant that is a nucleus contour advance multi-channel device.
Procedure Notes:
A general endotracheal anesthetic was administered. The right ear was examined and there was no evidence of ear infection. The right ear and face were prepped and draped in the standard sterile fashion.
An extended postauriclar incision(small incision made in the right inner ear) was created and brought down to the subgaleal level. Flaps were elevated and periosteal incisions were designed. The mastoid was widely exposed. A recess was created to accommodate the receiver/stimulator case. Mastoidotomy was then performed. The area of the aditus was identified and the short process of the incus exposed.
The facial recess was opened. The promontory was identified. The stapes and the area of the oval window was exposed as was the round window niche. A cochleostomy was performed. Holes were created at the lateral aspect of the receiver/stimulator recess and the mastoidotomy. The wound was irrigated copiously with sterile saline.
The device was then introduced into the field and secured in the recess. The ground electrode was placed deep to the temporalis fascia. The electrode array was inserted and a complete insertion was obtained with an advance off stylet technique. The cochleostomy was packed with soft tissue from the lateral incision. The stylet was removed and the wound was closed.(There are multiple steps to a coclear implant but only 1 code is needed as these steps are all considered part of the procedure.)
The ICD 10 PCS code for this procedure is:

Case Study #2:
Preoperative Diagnosis: Low back pain with lumbar facet arthropathy, lumbar radiculopathy.
Postoperative Diagnosis: Low back pain with lumbar facet arthropathy, lumbar radiculopathy.
Procedure: Spinal Cord Stimulator implant with neural modulation. (Code only the implant)

Procedure Note:

The patient was placed in the prone position and the back was aseptically prepped and draped. A local anesthesia was given. An epidural needle was then guided under fluoroscopic guidance to reach the epidural space by loss of resistance technique. The needle was then advanced to T8-9 level. The stimulator was analyzed, had good coverage of all her painful spots, the lead was anchored by extending the incision at the Para spinal area around L1-2 and then lead was anchored in the spinal canal with 2-0 silk. Dr. X did the pocket for the generator and completed the implant. The patient was discharged uneventfully.(Be careful with the body part on the implant. Read the documentation carefully.)

ICS 10 PCS code for the spinal cord stimulator implant only is:

Case Study #3:

Preoperative Diagnosis: Respiratory Failure, intracranial hemorrhage already intubated

Postoperative Diagnosis: Respiratory Failure, intracranial hemorrhage already intubated

Procedure: Tracheostomy (You can Google what this is and how it is done.)

Procedure Note:

The patient was prepped and draped in the normal sterile fashion and the anatomic landmarks of the thyroid cartilage and sternal notch were identified. About 1 fingerbreadth below the cricothyroid membrane, incision was made down to the level of the subcutaneous tissue. Bovie electrocautery was used to dissect down through the platysma. Any venous bleeders were identified and tied off with silk suture.

We had good exposure of the trachea. We identified the third tracheal ring. We placed suture on laterally on both sides of the third tracheal ring. This was carried down from skin to the tracheal ring back up to the skin. We made a square incision around the tracheal ring and removed this portion in square fashion. The ET tube was brought out proximally to this and a tracheal spreader was used to dilate the trachea. Here were no signs of bleeding and good hemostasis was achieved.

The skin around the tracheostomy incision was closed and secured in four places with nylon suture. The patient tolerated the procedure well and was returned to ICU.