ICD 10 CM PCS Coding Theory and

Practice 2018 Edition 1st Edition

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Chapter 08: Coding Medical and Surgical Procedures
Lovaasen: ICD-10-CM/PCS Coding: Theory and Practice, 2018 Edition

MULTIPLE CHOICE

1. ____ identifies procedure codes identified by the Medicare Code Editor as procedures covered
under limited circumstances.
a. Bilateral procedure
b. Nonspecific OR procedure
c. Noncovered OR procedure
d. Encoder
ANS: D DIF: M REF: p. 142 OBJ: 6
TOP: What Procedures Should Be Coded

2. Which of these is a true characteristic of significant procedures?

a. Surgical in nature
b. Carry a procedural risk
c. Carry an anesthetic risk
d. Require specialized training
e. All of the above
ANS: E DIF: M REF: p. 141 OBJ: 2
TOP: UHDDS Definitions

3. If a patient’s procedure is canceled before he or she shows up at the hospital, what is the
correct Z code to assign?
a. Z53.09 Surgical or other procedure not carried out because of contraindication
b. Z53.20 Surgical or other procedure not carried out because of patient’s decision
c. Z53.9 Procedure not carried out for other reasons
d. None of the above
ANS: D DIF: M REF: p. 144 OBJ: 3
TOP: Planned or Canceled Procedures

4. In some instances, a surgical wound is not closed at the time of a surgical operation and is
allowed to heal and will be closed at a later date. This is an example of when a ____ would be
coded.
a. closure
b. bilateral procedure
c. biopsy
d. limited coverage
ANS: A DIF: D REF: p. 146 OBJ: 6
TOP: What Procedures Should Be Coded

5. If a surgical procedure was canceled because the patient developed atrial fibrillation before
the start of the procedure, which Z code would be assigned?
a. Z53.09 Surgical or other procedure not carried out because of contraindication
b. Z53.20 Surgical or other procedure not carried out because of patient’s decision
c. Z53.9 Procedure not carried out for other reasons
 d. None of the above
ANS: A DIF: M REF: p. 144 OBJ: 3
TOP: Canceled Procedures

TRUE/FALSE

1. The Uniform Hospital Discharge Data Set (UHDDS) definitions are used by chronic care,
long-term hospitals to report inpatient data elements in a standardized manner.

ANS: F DIF: M REF: p. 141 OBJ: 1

TOP: UHDDS Definitions

2. Any procedure that affects payment or reimbursement must be reported.

ANS: T DIF: E REF: p. 142 OBJ: 4 | 6

TOP: What Procedures Should Be Coded

3. It is a routine part of most surgical procedures to close the operative wound(s), so it is not
necessary to code this separately.

ANS: T DIF: M REF: p. 146 OBJ: 6

TOP: ICD-10-PCS

4. If a surgical procedure starts out as a laparoscopic approach, it may never be converted to an

open procedure.

ANS: F DIF: D REF: p. 143 OBJ: 4

TOP: Closed Surgical Procedures and Conversion to Open Procedures

5. An additional code should always be assigned for closure of the surgical incision.

ANS: F DIF: M REF: p. 146 OBJ: 6

TOP: ICD-10-PCS

6. An obstetric procedure is any procedure performed on a pregnant woman.

ANS: F DIF: M REF: p. 121 OBJ: 6

TOP: Guideline

7. “Low cervical cesarean section” would be identified by the fifth character approach.

ANS: F DIF: M REF: pp. 121-122 OBJ: 10

TOP: Approach

8. When more than one procedure is performed, the procedure that was performed first is the
principal procedure.

ANS: F DIF: M REF: p. 141 OBJ: 1

TOP: Principal Procedure
 9. When a diagnostic procedure is performed for the principal diagnosis and a procedure for
definitive treatment is performed for a secondary diagnosis, the procedure for definitive
treatment is the principal procedure.

ANS: F DIF: M REF: p. 141 OBJ: 1

TOP: Principal Procedure

10. When a diagnostic procedure is performed for the principal diagnosis and a procedure for
definitive treatment is performed for a secondary diagnosis, the procedure for diagnostic
treatment is the principal procedure.

ANS: T DIF: M REF: p. 141 OBJ: 1

TOP: Principal Procedure

COMPLETION

1. ____________________ is the removal of tissue for pathologic exam to establish a precise

diagnosis.

ANS: Biopsy

DIF: E REF: p. 145 OBJ: 6 TOP: Biopsies

2. Each ____________________ should have its own written policy regarding the assignment of
ICD-10-PCS codes.

ANS: facility

DIF: E REF: p. 142 OBJ: 4 TOP: Facility Policies

3. When a patient shows up to have a procedure performed but the procedure is canceled for
whatever reason, the principal diagnosis would be ___________________.

ANS: the reason the patient was going to have the procedure done

DIF: E REF: p. 144 OBJ: 3

TOP: Planned or Canceled Procedures

4. Cutting off all or a portion of the upper or lower extremities is ____.

ANS: detachment

DIF: M REF: p. 149 OBJ: 5 TOP: Root Operation

5. Taking or letting out fluids and/or gases from a body part is called ____.

ANS: drainage

DIF: M REF: p. 150 OBJ: 5 TOP: Root Operation

6. Cutting out or off, without replacement, a portion of a body part is called ____.
 ANS: excision

DIF: M REF: p. 145 OBJ: 5 TOP: Root Operation

7. Freeing a body part from an abnormal physical constraint is called ____.

ANS: release

DIF: M REF: p. 153 OBJ: 5 TOP: Root Operation

8. Moving all or a portion of a body part to its normal location or other suitable location is called
____.

ANS: reposition

DIF: M REF: p. 154 OBJ: 5 TOP: Root Operation

9. Cutting into a body part without draining fluids and/or gases from the body part in order to
separate or transect a body part is called ____.

ANS: division

DIF: M REF: p. 153 OBJ: 5 TOP: Root Operation

10. Completely closing an orifice or lumen of a tubular body part is called ____.

ANS: occlusion

DIF: M REF: p. 157 OBJ: 5 TOP: Root Operation

11. Taking out or off a device from a body part is called ____.

ANS: removal

DIF: M REF: p. 159 OBJ: 5 TOP: Root Operation

12. Putting in or on biological or synthetic material that physically reinforces and/or augments the
function of a portion of a body part is called ____.

ANS: supplement

DIF: M REF: p. 160 OBJ: 5 TOP: Root Operation

13. Modifying the natural anatomic structure of a body part without affecting the function of the
body part is called ____.

ANS: alteration

DIF: M REF: p. 162 OBJ: 5 TOP: Root Operation

14. Stopping, or attempting to stop, postprocedural or other acute bleeding is called ____.
 ANS: control

DIF: M REF: pp. 161-162 OBJ: 5 TOP: Root Operation

15. Visually and/or manually exploring a body part is called ____.

ANS: inspection

DIF: M REF: pp. 160-161 OBJ: 5 TOP: Root Operation

MATCHING

Match each definition to one of the following items.

a. Drainage
b. Excision
c. Occlusion
d. Release
e. Removal
f. Reposition

1. Root operation to remove some/all of a body part

2. Root operation to remove solids/fluids/gases from a body part
3. Root operation that involves cutting or separation only
4. Root operation that puts in/puts back or moves some/all of a body part
5. Root operation that alters the diameter/route of a tubular body part
6. Root operation that always involves a device

1. ANS: B DIF: M REF: p. 145 OBJ: 5

TOP: Root Operation
2. ANS: A DIF: M REF: p. 145 OBJ: 5
TOP: Root Operation
3. ANS: D DIF: M REF: p. 153 OBJ: 5
TOP: Root Operation
4. ANS: F DIF: M REF: p. 154 OBJ: 5
TOP: Root Operation
5. ANS: C DIF: M REF: p. 157 OBJ: 5
TOP: Root Operation
6. ANS: E DIF: M REF: p. 159 OBJ: 5
TOP: Root Operation

SHORT ANSWER

1. Above-knee amputation, right midshaft femoral region

ANS:
0Y6C0Z2

DIF: M REF: p. 149 OBJ: 6 TOP: ICD-10-PCS

2. ESWL—right ureter

ANS:
0TF6XZZ

DIF: M REF: p. 152 OBJ: 6 TOP: ICD-10-PCS

3. Bilateral fallopian tubal occlusion with Falope ring device, laparoscopic approach

ANS:
0UL74CZ

DIF: M REF: p. 157 OBJ: 6 TOP: ICD-10-PCS

4. Laparoscopic Nissen fundoplication

ANS:
0DV44ZZ

DIF: M REF: p. 157 OBJ: 6 TOP: ICD-10-PCS

5. Therapeutic paracentesis of peritoneal cavity, percutaneous

ANS:
0W9G3ZZ

DIF: M REF: p. 151 OBJ: 6 TOP: ICD-10-PCS

6. Left kidney transplant, cadaver donor

ANS:
0TY10Z0

DIF: M REF: p. 155 OBJ: 6 TOP: ICD-10-PCS

7. Open CABG bypass of two coronary arteries using the saphenous vein (aorta to coronary
artery) and one artery with the left internal mammary artery, which was used as a pedicle graft
to coronary artery. The left greater saphenous vein was harvested via percutaneous endoscopic
approach. Cardiopulmonary bypass machine was used during the procedure.

ANS:
021109W, 02100Z9, 06BQ4ZZ, 5A1221Z

DIF: D REF: p. 156 OBJ: 6 TOP: ICD-10-PCS

8. PTCA of left anterior descending and left circumflex

ANS:
02713ZZ

DIF: D REF: p. 157 OBJ: 6 TOP: ICD-10-PCS

 9. Removal of drainage device from right pleural cavity, external approach

ANS:
0WP9X0Z

DIF: M REF: p. 159 OBJ: 6 TOP: ICD-10-PCS

10. Total right hip replacement with ceramic on polyethylene prosthesis, open approach, without
bone cement

ANS:
0SR904A

DIF: M REF: pp. 146-147 OBJ: 6 TOP: ICD-10-PCS

11. Laparoscopic cholecystectomy converted to open cholecystectomy

ANS:
0FT40ZZ, 0FJ44ZZ

DIF: D REF: pp. 147-148 OBJ: 6 TOP: ICD-10-PCS

12. Closed reduction of right radial fracture

ANS:
0PSHXZZ

DIF: M REF: p. 154 OBJ: 6 TOP: ICD-10-PCS

13. Percutaneous aspiration of left perirenal abscess

ANS:
0T913ZZ

DIF: D REF: p. 151 OBJ: 6 TOP: ICD-10-PCS

14. Removal of mole right upper arm

ANS:
0HBBXZZ

DIF: M REF: p. 150 OBJ: 6 TOP: ICD-10-PCS

15. Laparoscopic-assisted vaginal hysterectomy

ANS:
0UT9FZZ

DIF: M REF: p. 147 OBJ: 6 TOP: ICD-10-PCS

16. Episiotomy with vaginal delivery

 ANS:
10E0XZZ, 0W8NXZZ

DIF: M REF: pp. 122, 153 OBJ: 6 TOP: ICD-10-PCS

17. Frenulotomy for treatment of ankyloglossia

ANS:
0CN7XZZ

DIF: M REF: p. 153 OBJ: 6 TOP: ICD-10-PCS

18. Heart transplant, cadaver donor with extracorporeal circulation auxiliary during the open-heart
surgery

ANS:
02YA0Z0, 5A1221Z

DIF: D REF: pp. 126, 155 OBJ: 6 TOP: ICD-10-PCS

19. Lysis of small intestinal adhesions, open approach

ANS:
0DN80ZZ

DIF: M REF: p. 153 OBJ: 6 TOP: ICD-10-PCS

20. Open thyroidectomy with removal of the entire right lobe

ANS:
0GTH0ZZ

DIF: D REF: p. 147 OBJ: 6 TOP: ICD-10-PCS

21. Ureteroscopy that was unsuccessful for stone removal, left ureter

ANS:
0TJ98ZZ

DIF: D REF: p. 160 OBJ: 6 TOP: ICD-10-PCS

22. Nonexcisional debridement of skin—right foot ulcer

ANS:
0HDMXZZ

DIF: M REF: p. 150 OBJ: 6 TOP: ICD-10-PCS

23. Open endarterectomy of right internal carotid artery

ANS:
03CK0ZZ
 DIF: M REF: p. 151 OBJ: 6 TOP: ICD-10-PCS

24. Transurethral endoscopic laser ablation of prostate

ANS:
0V508ZZ

DIF: M REF: p. 149 OBJ: 6 TOP: ICD-10-PCS

25. Reattachment of right thumb

ANS:
0XML0ZZ

DIF: M REF: p. 153 OBJ: 6 TOP: ICD-10-PCS

26. Laparoscopic orchiopexy—right undescended testicle

ANS:
0VS94ZZ

DIF: M REF: p. 154 OBJ: 6 TOP: ICD-10-PCS

27. Placement of central venous catheter with the tipat the cavoatrial junction

ANS:
02HV33Z

DIF: D REF: p. 158 OBJ: 6 TOP: ICD-10-PCS

28. Change of nephrostomy tube

ANS:
0T25X0Z

DIF: M REF: p. 158 OBJ: 6 TOP: ICD-10-PCS

29. Percutaneous repositioning of dislocated atrial pacemaker lead

ANS:
02WA3MZ

DIF: D REF: p. 159 OBJ: 6 TOP: ICD-10-PCS

30. Open annuloplasty of the mitral valve with Carpentier-Edwards ring

ANS:
02UG0JZ

DIF: D REF: p. 160 OBJ: 6 TOP: ICD-10-PCS