· Extraction of Endometrium, Via Natural or Artificial Opening, Diagnostic ICD-10-PCS 0UDB7ZX is a specific/billable code that can be used to indicate a procedure. ICD-10-PCS 0UDB7ZX is intended for females as it is clinically and virtually impossible to …
ICD-10-CM Diagnosis Code N85.00 [convert to ICD-9-CM] Endometrial hyperplasia, unspecified. Benign (not cancer)endometrial hyperplasia; Benign endometrial hyperplasia; Endometrial hyperplasia; Hyperplasia (adenomatous) (cystic) (glandular) of endometrium; Hyperplastic endometritis. ICD-10-CM Diagnosis Code N85.00.
ICD-10-PCS Procedure Code 0UDB8ZZ [convert to ICD-9-CM] Extraction of Endometrium, Via Natural or Artificial Opening Endoscopic. ICD-10-CM Diagnosis Code Q51.9 [convert to ICD-9-CM] Congenital malformation of uterus and cervix, unspecified. Congenital uterine anomaly; Inadequate development of endometrium.
· In the 2016 ICD-10-PCS Official Guidelines for Coding and Reporting Biopsy procedures B3.4a Biopsy procedures are coded using the root operations Excision, Extraction, or Drainage and the qualifier Diagnostic. The qualifier Diagnostic is used only for biopsies.
Biopsy procedures B3. 4a Biopsy procedures are coded using the root operations Excision, Extraction, or Drainage and the qualifier Diagnostic. The qualifier Diagnostic is used only for biopsies.
operation extractionBone marrow and endometrial biopsies are not coded to excision. Instead they are coded to the root operation extraction, with the qualifier diagnostic used to identify the biopsy.
The term “excision” itself describes the simultaneous process of making the incision and extracting the entire follicle. An “incision” only describes the actual cut, and the “extraction” the removal of the follicle.
In ICD-10-PCS the seventh character defines the qualifier – i.e., an additional attribute of the procedure, if applicable.
In ICD-10-PCS coding, the root operation must be determined at the start of trying to assign a specific code for the procedure. The root operation is the third character in the PCS code and describes the intent or the objective of the procedure.
The third character of ICD-10-PCS defines the root operation. Some other examples of root operations are Bypass, Drainage, and Reattachment etc. When used in the third character of the code, the value B represents Excision.
ICD-10-PCS will be the official system of assigning codes to procedures associated with hospital utilization in the United States. ICD-10-PCS codes will support data collection, payment and electronic health records. ICD-10-PCS is a medical classification coding system for procedural codes.
17 sectionsThere are 17 sections to ICD-10-PCS. The sections relate to the type of procedure being performed. They are the following: Medical and surgical.
Excisional surgery or shave excision is a surgical procedure that involves the removal of growths, such as moles, masses and tumors, from the skin along with the healthy tissues around the tumor. The doctor uses this technique to treat skin cancers, where they use a scalpel or razor to remove the tumor.
The qualifier Diagnostic is used only for biopsies. A colonoscopy with biopsy of transverse colon is coded to root operation Excision and qualifier Diagnostic. If a colonoscopy is done to remove a polyp, and the polyp is sent to pathology, do NOT use qualifier X –diagnostic.
ICD-10-PCS describes seven different approaches: open, percutaneous, percutaneous endoscopic, via natural or artificial opening, via natural or artificial opening endoscopic, via natural or artificial opening with percutaneous endoscopic assistance, and external.
Biopsy procedures are coded using the root operations Excision, Extraction, or Drainage and the qualifier Diagnostic. The qualifier Diagnostic is used only for biopsies. Examples: Fine needle aspiration biopsy of lung is coded to the root operation Drainage with the qualifier Diagnostic.
Needle biopsy of bone marrow of the iliac crest: 07DR3ZX
Biopsy followed by more definitive treatment. B3.4b. If a diagnostic Excision, Extraction, or Drainage procedure (biopsy) is followed by a more definitive procedure, such as Destruction, Excision or Resection at the same procedure site, both the biopsy and the more definitive treatment are coded.
In ICD-9-CM, the Alphabetic Index entry main term Ablation, subterm endometrium identifies code 68.23, Endometrial ablation. Code 68.23 would be assigned whether or not a scope was utilized during the procedure.
The Alphabetic Index entry main term Extraction, subterm Bone Marrow refers the coding professional to Table 07D. The ICD-10-PCS code for this procedure is 07DR3ZX. The fourth character (R) identifies the body part as bone marrow, iliac. Unlike ICD-9-CM, the code specifies the specific location of the bone marrow biopsy.
The fourth character (B) identifies the body part as the endometrium and the fifth character (7) identifies the approach as via natural opening.
The fifth character of the code identifies the technique used to reach the operative site. The approach for the bone marrow biopsy was percutaneous (3). In ICD-10-PCS the fifth character always identifies the specific approach utilized to reach the operative site.
During this procedure the Therma-Choice catheter with balloon was placed inside the endometrial cavity and slowly filled with fluid until it stabilized at a pressure of approximately 175 to 180 mmHg. Eight minutes of therapeutic heat was applied to the lining of the endometrium.
The ICD-10-PCS code for this procedure is 0Y6N0ZF. The fourth character (N) identifies the body part as the left foot and the seventh character (F) identifies the level of detachment as partial fifth ray. The definition for partial fifth ray is amputation anywhere along the shaft or head of the fifth metatarsal bone of the foot. The fifth character identifies the technique to reach the operative site or approach. The procedural approach was open (0) because an incision was made to reach the operative site.
Editor's note: This is the second in a series of 10 articles discussing the 31 root operations of ICD-10-PCS.