1.  087X0DZ Root Operation: Dilation, Duct, Lacrimal, Right (087X)

Rationale: This procedure is coded to the root operation Dilation since the right lacrimal duct was dilated. The osteotomy is the approach, which is open. The sixth character for the device (silicone tube) is D, Intraluminal device.

2.  0B110F4 Root Operation: Bypass, Trachea (0B11) Tracheostomy, see, Bypass, Respiratory System (0B1)

Rationale: This procedure is coded to the root operation Bypass. A tracheostomy is a bypass between the trachea and skin. The body part value 1, Trachea, is the source of the bypass (or where the bypass is coming from) and the skin (Cutaneous, 4) is the body part bypassed to. A Shiley trach was left at the operative site, therefore the device value of F, Tracheostomy, is assigned for the sixth character.

3.  0TL60ZZ Root Operation: Occlusion, Ureter, Right (0TL6)

Rationale: The root operation for ligation is Occlusion. The body part value is 6 for right ureter. There was not a device left, so the value is Z.

4.  0UVC0CZ Root Operation: Restriction, Cervix (0UVC) Cerclage, see Restriction

Rationale: The root operation for the cervical cerclage is Restriction. The objective of this procedure is to partially close the cervix. The device value is C, Extraluminal Device, to capture the band that was placed around or on the outside of the cervix.

5.  0DV64CZ Root Operation: Restriction, Stomach (0DV6)

Rationale: The root operation for banding is Restriction. The entire seven characters can be found in the Index, under Banding, laparoscopic (adjustable) gastric, initial procedure. Although the seven characters are in the Index, view the table to ensure proper character assignment.

6.  03VG3DZ Root Operation: Restriction, Artery, Intracranial (03VG)

Rationale: The root operation for this procedure is Restriction because placement of the coils narrows the lumen of the anterior cerebral artery but does not close it off entirely. The anterior cerebral artery does not have its own body part value in ICD-10-PCS. Utilizing the Alphabetic Index, the anterior cerebral artery maps to the intracranial artery body part in ICD-10-PCS.

A cerebral aneurysm is also known as an intracranial or intracerebral aneurysm and is a weak area on a blood vessel in the brain that balloons out and fills with blood. The device value for the coated platinum coils is D, Intraluminal Device.

Utilizing the Device Table or the Alphabetic Index the term Embolization coils maps to an Intraluminal Device.

7.  

021109W Root Operation: Bypass, Artery, Coronary, Two Arteries (0211)

02100Z9 Root Operation: Bypass, Artery, Coronary, One Artery (0210)

06BQ4ZZ Root Operation: Excision, Vein, Saphenous, Left (06BQ)

Rationale: The diagonal and obtuse margin arteries were bypassed using the aortocoronary bypass grafting technique. This technique involves graft material which for this case was autologous venous tissue. The graft material came from the patient’s own left greater saphenous vein.

The coronary artery bypass graft of the left anterior descending artery was done using the left internal mammary artery.

Review Coding Guideline B3.6b for coronary arteries. The body part value identifies the number of coronary arteries bypassed to and the qualifier identifies the vessel bypassed from. The sixth character, No Device, was selected because internal mammary artery was used as a pedicle graft. The internal mammary was loosened from one side and brought around to the occluded coronary artery, restoring blood flow

8.  

027034Z Root Operation: Dilation, Artery, Coronary, One Artery (0270)

02703ZZ Root Operation: Dilation, Artery, Coronary, One Artery (0270)

Rationale: Two codes are required for this procedure with a separate code required for each artery dilated, because the device value differs for each artery.

For the body part value, select Coronary Artery, One Artery (0), because a drug-eluting stent was used in one artery, but not the other. The device character 4 was assigned for the procedure with the drug-eluting stent (Coding Guideline B4.4).

9. 027135Z Root Operation: Dilation, Artery, Coronary, Two Arteries (0271).

Because 2 drug-eluting stents were used in 2 arteries. The device character 5 was assigned for the procedure with the 2 drug-eluting stents (Coding Guideline B4.4).

10.  0UL74CZ Root Operation: Occlusion, Fallopian Tubes, Bilateral (0UL7)

Rationale: The root operation for ligation is occlusion. Body part character 7 is assigned for bilateral. If there was not a bilateral character, two codes would be assigned. One code for the right side and one code for the left side.

11. 0D738ZZ Root Operation: Dilation, Esophagus, Lower (0D73)

Rationale: The dilation was performed in the distal, or lower, part of the esophagus.

12. 0D1M0Z4 Root Operation: Bypass, Colon, Descending (0D1M)

Rationale: The fourth character of this procedure code specifies the body part bypassed from (descending colon) and the seventh character specifies the body part bypassed to (skin).

13. 04LE3DT Root Operation: Occlusion, Artery, Internal Iliac, Right (04LE) 04LF3DU Root 

Operation: Occlusion, Artery, Internal Iliac, Left (04LF)

Rationale: Two codes are required for this procedure—one for the embolization of the right uterine artery and one for the embolization of the left uterine artery. The uterine arteries do not have their own body part values in ICD-10-PCS. Utilizing the Alphabetic