SCHIMA ICD-10 C6 Attendee Handouts
Course C6
Root Operation That
Put In / Put Back
or
Move Some / All
of a Body Part
January/February/March
2013
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-PCS
Transplantation
Definition – 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.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-PCS
Transplantation
A small number of procedures are
represented by the root operation
“Transplantation” and includes only the
body part currently being transplanted.
Examples of Transplantation procedures:
• Heart Transplant
• Kidney Transplant
• Lung Transplant
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-PCS
Transplantation
ICD-10-PCS
Transplantation
During the “Transplantation”, the
native body part may or may not be
taken out.
Qualifier values specify the genetic
compatibility of the body part
transplanted.
Type of Transplant
The transplanted body part may take
over all or a portion of it’s function.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
Qualifier Character
Definition
Allogenic
0
Taken from different individuals of the same species
Syngeneic
1
Having to do with individuals or tissues that have identical genes, such as identical twins
Zooplastic
2
Tissue from an animal to a human
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
1
SCHIMA ICD-10 C6 Attendee Handouts
ICD-10-PCS
Transplantation
Coding Hint:
PCS does not include corneas & heart
valves in the Transplantation Root
Operation. They are classified to
“Replacement” as they are considered
biologic or synthetic and not a
“complex body part”.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-PCS Transplantation Coding
Exercises
Liver transplant with donor
matched liver.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-PCS Transplantation Coding
Exercises
Heart transplant using a porcine
heart.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-PCS
Transplantation
Coding Hint, cont’d.
Transplantation vs. Administration
(Body parts) vs. (cells)
Don’t confuse the two
“putting in” autologous or
nonautologous cells (i.e. bone marrow,
pancreatic islet cells, stem cells) are
coded to Administration.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-PCS Transplantation Coding
Exercises
Bilateral lung transplant, using
an organ donor match.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-PCS Transplantation Coding
Exercises
Right kidney transplant using a
twin brother’s kidney.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
2
SCHIMA ICD-10 C6 Attendee Handouts
ICD-10-PCS
Reattachment
Root Operation That
Put In / Put Back
or
Move Some / All
of a Body Part
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-PCS
Reattachment
“Separated” refers to a body part
that has been cut off or avulsed
(the ripping or tearing away of a
part either accidentally or
surgically).
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
Definition – Putting back in or on
all or a portion of a separated
body part to it’s normal location
or other suitable location.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-PCS
Replacement
Examples of Reattachment procedures:
• Reattachment of a severed finger
• Reattachment of an avulsed kidney
• Closed replantation of avulsed teeth of
upper jaw
• Replantation of avulsed scalp
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-PCS
Reattachment
ICD-10-PCS Reattachment Coding
Exercises
Coding Hint: Vascular
circulation and nervous
pathways may or may not be
reestablished.
Reattachment of severed left ear
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
3
SCHIMA ICD-10 C6 Attendee Handouts
ICD-10-PCS Reattachment Coding
Exercises
ICD-10-PCS Reattachment Coding
Exercises
Reattachment of right hand
Endoscopic reattachment of an
avulsed tendon of the left knee
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-PCS Reattachment Coding
Exercises
MEDICAL & SURGICAL ROOT
OPERATIONS
Reattachment of right severed
fallopian tube
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
Transfer: Moving, without taking out, all
or a portion of a body part to another
the location, to take over the function
of all or a portion of a body part.
Examples:
– Tendon transfer, skin pedicle flap transfer,
skin transfer flap
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
• Additional Examples:
– Trigeminal to fascial nerve transfer
– Left scalp advancement flap to left
temple
– Transfer right index finger to right thumb
position
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
4
SCHIMA ICD-10 C6 Attendee Handouts
• Transfer is used to represent procedures where
a body part is moved to another location
without disrupting its vascular and nervous
supply. In the body systems that classify the
subcutaneous tissue, fascia and muscle body
parts, a qualifier is used to specify when more
that one tissue layer was used in the transfer
procedure, such as a musculocutaneous flap
transfer.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
• Case # 1:
– Patient underwent a left foot open flexor
digitorum brevis tendon transfer.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
• Case #3:
– Skin transfer flap closure of complex open
wound, right chest
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
• Body System Value:
– The body system value describes the
deepest tissue layer in the flap. The
qualifier can be used to describe the
other tissue layers, if any, being
transferred.
• Note: Free grafts are coded to the
root operation of Replacement
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
• Case # 2:
– Patient underwent an endoscopic radial
to median nerve transfer
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
MEDICAL & SURGICAL ROOT
OPERATIONS: REPOSITION
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
5
SCHIMA ICD-10 C6 Attendee Handouts
• Reposition:
– To reposition is to move all or a portion of a
body part to its normal location or other
suitable location.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
• Examples of Reposition procedures
include:
– reduction of fractures
– reposition of undescended testicle
– transposition of a nerve
– repositioning of a ligament.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
• Case # 1:
– Patient underwent an open reduction of
a displaced fracture of the right humeral
head.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
• The Reposition root operation is used for those
procedures where a body part is moved or
relocated to a new position or location. The
range of reposition includes moving the body
part to its normal location or a new location to
enhance the body part’s ability to function.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
• Reduction of a displaced fracture is
coded to the root operation
Reposition and the application of the
cast or splint is not coded separately.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
• Case # 2:
– Patient underwent a bilateral
percutaneous repositioning of his testicles
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
6
SCHIMA ICD-10 C6 Attendee Handouts
• Case #3:
– Patient underwent a closed reduction
with percutaneous internal fixation of a
left intertrochanteric femoral fracture
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
MEDICAL & SURGICAL ROOT
OPERATIONS: RESTRICTION
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-PCS
Restriction
ICD-10-PCS
Restriction
Root operations that alter the diameter/route of a
Tubular Body Part
Definition: Partially closing an orifice or
the lumen of a tubular body part
There are four operations that belong to this group
- Restriction
- Occlusion
- Dilation
- Bypass
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-PCS
Restriction
Some of these conditions are:
• Esophagogastric fundoplication
• Cervical cerclage
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
Explanation: The orifice can be a
natural orifice or an artificially created
orifice
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-PCS
Restriction
The root operation Restriction is coded
when the objective of the procedure is
to narrow the diameter body part or
orifice. Restriction includes either
intraluminal or extraluminal methods
for narrowing the diameter.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
7
SCHIMA ICD-10 C6 Attendee Handouts
ICD -10- PCS
Restriction
Additional examples of restriction
• Thoracotomy with banding of the left
pulomary artery with extraluminal
device
• Restriction of thoracic duct with
intraluminal stent
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD -10- PCS Restriction
* Since intraluminal or extraluminal clips
are frequently used to accomplish the
objectives of Restriction and Occlusion
procedures , careful review of the
operative report is required. Research
on the procedure technique may also
be helpful.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-PCS Restriction Coding
Exercises
Restriction of thoracic duct with
intraluminal stent
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD -10- PCS Restriction
Continued…
• Non-incisional, trans-nasal placement
of restrictive stent in lacrimal duct
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-PCS Restriction Coding
Exercises
Transvaginal cervical cerclage using
Mcdonald technique
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-PCS Restriction Coding
Exercises
Clipping of anterior cerebral artery
aneurysm via craniotomy
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
8
SCHIMA ICD-10 C6 Attendee Handouts
ICD-10-PCS
Occlusion
MEDICAL & SURGICAL ROOT
OPERATIONS: OCCLUSION
Definition: Complete closing an orifice
or the lumen of a tubular body part
Explanation: The orifice can be a
natural orifice or an artificially created
orifice.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-PCS
Occlusion
Examples:
• Fallopian tube ligation
• Ligation of inferior vena cava
• Uterine artery embolization
(complete closing the vessel)
• Complete embolization of internal
carotid-cavernous fistula
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-PCS
Occlusion
Coding Guideline B3.12.
Occlusion vs. Restriction for Vessel
Embolization
If the objective of an embolization
procedure is to completely close a vessel,
the root operation Occlusion is coded. If the
objective of an embolization procedure is to
narrow the lumen of the vessel, the root
operation Restriction is coded.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-PCS
Occlusion
ICD-10-PCS
Occlusion
Example:
1. Tumor embolization is coded to the
root operation Occlusion, because
the objective of the procedure is to
cut off the blood supply to the vessel.
Example:
2. Embolization of a cerebral aneurysm is
coded to the root operation
Restriction, because the objective of
the procedure is not to close off the
vessel entirely, but to narrow the lumen
of the vessel at the site of the
aneurysm where it is abnormally wide.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
9
SCHIMA ICD-10 C6 Attendee Handouts
ICD-10-PCS
Occlusion
ICD-10-PCS
Occlusion
*Research on embolizations may be required
to gain additional information about how
the procedure is performed. The purpose of
an embolization is to prevent blood flow to
and area of the body. It is used during
hemorrhage (i.e. arteriovenous AV
malformation, cerebral aneurysms, GI
bleeding, epistaxis, post-partum
hemorrhage).
However, the procedure has other
uses, such as in the treatment of
tumors and disorders of the portal vein.
An artificial embolus is introduced
(coils, particles, foam, plugs). Some of
the common agents used to do this
are sclerosing agents, ethanol, or
Gelfoam.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-PCS
Occlusion
In order to code occlusions and
restrictions correctly the coder must
know if it is complete or partial, and
physician documentation or additional
query is essential.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-PCS Occlusion Coding
Exercises
Laparoscopy with bilateral occlusion
of fallopian tubes using extraluminal
clips
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-PCS Occlusion Coding
Exercises
ICD-10-PCS Occlusion Coding
Exercises
Percutaneous ligation of left external
jugular vein
Open suture ligation of failed AV graft,
right brachial artery
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
10
SCHIMA ICD-10 C6 Attendee Handouts
ICD-10-PCS Occlusion Coding
Exercises
Uterine artery embolization, right
(completely closing the vessel)
ROOT OPERATIONS:
DILATION (7) & BYPASS (1)
*No device used
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
• 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.
• Examples - PTCA, dilation of laryngeal stenosis,
dilation of common bile duct
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
Applicable Coding Guidelines:
• B4.4 Coronary Arteries
The coronary arteries are classified as a single body
part that is further specified by the number of sites
treated and not by name or number of arteries.
Separate body part values are used to specify the
number of sites treated when the same procedure
is performed on multiple sites in the coronary
arteries.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
• The root operation dilation is coded when the
objective of the procedure is to enlarge the
diameter of a tubular body part or orifice.
• Includes both intraluminal and extraluminal
methods of enlarging the diameter.
• A device placed to maintain the new diameter is
an integral part of the dilation procedure and is
coded to a sixth character device value in the
dilation procedure code.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
Applicable Coding Guidelines: B4.4 Coronary Arteries
– continued
Examples:
1. Angioplasty of two distinct sites in the LAD coronary artery
with placement of 2 stents is coded as Dilation of Coronary
Arteries, Two Sites with Intraluminal Device
2. Angioplasty of two distinct sites in the LAD coronary artery
one with stent placement and one without is codes
separately as: Dilation of Coronary Artery, One Site with
Intraluminal Device and Dilation of Coronary Artery One Site
with No Device.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
11
SCHIMA ICD-10 C6 Attendee Handouts
1. ERCP with balloon dilation of common bile duct
2. PTA of right radial artery stenosis
3. Laryngoscopy with intraluminal dilation of
laryngeal stenosis
4. PTCA of 2 coronary arteries – RCA with stent and
LAD without stent
5. Hysteroscopy with balloon dilation of fallopian
tubes
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
Applicable Coding Guidelines:
• B3.6a Bypass Procedures
Bypass procedures are coded by identifying the
body part bypassed “from” and the body part
bypassed “to”. The fourth character body part
specifies the body part bypassed from and the
qualifier specifies the body part bypassed to.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
Applicable Coding Guidelines:
• B3.6c Coronary Bypass Procedures
If an autograft is obtained from a different body part
in order to complete the objective of the
procedure, a separate procedure is coded.
Example – Coronary bypass with saphenous vein
graft, excision of saphenous vein is coded
separately.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
• Definition – Altering the route of passage of the
contents of a tubular body part.
• Explanation – Rerouting content of a body part to a
“downstream” area of the normal route, to a similar
route and body part, or to an abnormal route or
dissimilar body part. Includes on or more
anastomoses with or without the sue of a device.
• Examples – CABG, Colostomy formation
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
Applicable Coding Guidelines:
• B3.6b Coronary Bypass Procedures
Coronary arteries are classified by number of distinct sites
treated, rather than number of coronary arteries or anatomic
name of a coronary artery. Coronary artery bypass
procedures are coded differently than other bypass
procedures as described in guidelines B3.6a. Rather than
identifying the body part bypassed from, the body part
identifies the number of coronary artery sites bypassed to, and
the qualifier specifies the vessel bypassed from.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
Coronary Artery Bypass – Devices
Type of Tissue
Autologous artery or vein
Device
Character
9 or A
Definition
Tissue or organ is transferred into a new position in the body of the same individual
Synthetic Substitute
J
Any type of synthetic substitute Nonautologous Tissue Substitute K
Nonautologous allogenic donor; tissue implanted from one human to another
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
12
SCHIMA ICD-10 C6 Attendee Handouts
Coronary Artery Bypass – Devices
• When assigning the device value, the key to
remember is that to be considered a device, this
needs to be material used as a graft (separated)
and not moved over. When the internal mammary
is loosened from one side and brought around to
the occluded coronary artery, the artery is not used
as free graft material – in this case No Device is the
appropriate qualifier.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
1. Open colostomy, descending colon to abdominal
wall
2. CABG of three coronary arteries using left
autologous greater saphenous vein, harvested
endoscopically
3. Right femoral-posterior tibial artery bypass using
cadaver vein graft, open approach
4. Open gastric bypass with Roux-en-Y limb to jejunum
5. CABG of LAD using left internal mammary artery.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-CM/PCS Coding
Case # 1
CASE STUDIES
Preoperative Diagnosis: Gastroesophageal reflux
disease with biliary colic and cholecystitis
Postoperative Diagnosis: Gasgtroesophageal reflux
disease with biliary colic and cholecystitis
Procedure: Laparoscopic Nissen fundoplication with
laparoscpic cholecystectomy
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-CM/PCS Coding
Case # 1
Description: Her abdomen was prepped and draped. A 5 mm
stab incision was made to the left of the umbilicus. The
abdomen was briefly explored with the laparascope, and we
placed four 5 mm trocars across the upper abdomen. We
exposed the gastroesophageal junction. We began by taking
down the gastrohepatic window and cleaning up the right
crus of the diaphragm. We then turned and took down the
top most splenic short gastric vessels freeing up the fundus of
the stomach We cleaned up the left crus of the diaphragm
and created a nice window behind the esophagus. We
wrapped the fundus of the stomach around the esophagus to
create a nice loose, floppy Nissen fundoplication.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-CM/PCS Coding
Case # 1
And then we focused on the gallbladder. The
dome of the gallbladder was elevated. We
carefully skeletonized the cystic duct and
cystic artery and then divided these
between the Hemoclips. The remainder of
the gallbladder was dissected free. The
gallbladder was removed through the right
lateral trocar site. The trocars were removed
under laparoscopic visualization
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
13
SCHIMA ICD-10 C6 Attendee Handouts
ICD-10-CM/PCS Coding
Case # 2
Preoperative Diagnosis: ESRD secondary to dysplasia, peritoneal
dialysis dependent
Postoperative Diagnosis:ESRD secondary to dysplasia, peritoneal
dialysis dependent
Procedure: Living related donor renal transplant
The midline incision and access to the transplant was completed
in standard fashion. The donor kidney was procured in a
separate procedure. The patient was systematically heparinized
with 1,000 units intravenously. After 3 minutes cross clamps were
placed and he donor kidney was transplanted and all vascular
anastomoses were completed without complication and patient
was transported to ICU
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-CM/PCS Coding
Case # 3
Description of Procedure:
The patient was sedated and brought
to the cath lab. Via standard femoral
artery access the patient underwent a
angioplasty and DES stent placement in
the LAD and a bare metal stent in the
RCA. Good results were obtained.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-CM/PCS Coding
Case # 3
Pre-op Diagnoses:
Coronary atherosclerosis with unstable angina
Hypertensive heart disease with CHF
Type I Diabetes
Post-op Diagnoses: Same
Procedure: PTCA of LAD and RCA
HPI: 62 year old female transferred from another facility after
diagnostic cath showing two vessel CAD. This will be the patient’s
first cardiac intervention.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-CM/PCS Coding
Case # 4
Pre-Op Diagnoses : Severe RLE
atherosclerosis of native arteries with rest
pain, Hypertension, ESRD, Alzheimer’s
dementia.
Post-op Diagnoses: Same
Procedure: Right femoral to posterior
tibial with saphenous bypass
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-CM/PCS Coding
Case # 4
ICD-10-CM/PCS Coding
Case # 5
Procedure Description:
The right groin was opened and the femoral vessels were all
dissected out and controlled individually, The medial calf was
opened and an excellent greater saphenous vein was dissected
out. We deepened the incision and identified the posterior tibial
artery. After 2000units of heparin the posterior tibial artery was
opened and an arteriotomy was made across the origin of the
SFA. The saphenous vein was amputated and the graft was was
anastomosed on both ends.
Pre-op Diagnosis: Dysphagia
Post-op Diagnosis: Esophageal stricture
Operation: Gastroscopy with balloon dilation of esophagus
Description: The Olympus was passed into the stomach and
withdrawn back to the distal esophagus. A balloon dilation was
performed in graduation from 36 French to 45 French and the
balloon was inflated for 60 seconds. The stomach was normal on
endoscopic exam.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
14
SCHIMA ICD-10 C6 Attendee Handouts
ICD-10-CM/PCS Coding
Case # 6
ICD-10-CM/PCS Coding
Case # 7
Pre-op Diagnosis: Laceration with foreign body (broken glass) on
the left little finger at the metacarpal phalangeal joint. Cut
sustained when patient was washing dinner dishes in her house.
Post-op Diagnosis: Same
Procedure: Exploration of MP joint with excision and removal of
foreign body – broken glass.
Description: An oblique incision was made over the MP joint.
Incision was deepened and bleeders were fulgurated. By careful
sharp and blunt dissection the foreign body was searched for.
The foreign body was wedged underneath the foot of the
tendon in the joint space; it was completely extracted and
removed. The wound was irrigated and closed with 5-0 nylon.
Pre-op Diagnosis: Acute anterior wall STEMI; Acute posterior wall
STEMI two weeks ago.
Post-op Diagnosis: Same
Procedure: Off Pump CABG
Description: The greater saphenous vein was harvested via
incision from the left lower extremity, sufficient for 3 bypass grafts.
The chest was opened through a median sternotomy incision.
The pleural cavity was opened and the left internal mammary
artery was mobilized. Using the vein graft the distal ic
anastomoses were accomplished first. Individual segments of the
saphenous vein were then sewn to the obtuse marginal ,
circumflex and distal right artery respectively with running sutures
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
ICD-10-CM/PCS Coding
Case # 7
of 7-0 Prolene. The left internal mammary artery was then
brought through a window in the pericardium and was sewn to
the LAD with 8-0 Prolene. Three buttons of aortic tissue were
excised and used as the 3 proximal anastomoses for saphenous
grafts were completed with sutures 6-0 Prolene.
The chest was closed in layers in usual fashion and dry sterile
dressing applied.
Copyright © 2011 South Carolina Health Information Management Association. All rights reserved.
15