In ICD 10 PCS we have around 31 icd 10 pcs root operations for coding procedure codes. Out of these we have already discussed few of them previously. Today, we try to learn when to use root operation RESECTION: one of icd 10 pcs root operations for coding ICD 10 PCS codes. Root operation defines the main objective of the procedure. It is the third character of the ICD 10 PCS code. Each root operation have a particular character value. Like for Excision it has a Character value B and for Resection it has Character value T. In short, in ICD 10 PCS code the third character B and T represent the root operation excision and resection respectively. If you good in coding correct root operation, you can become perfect in surgery coding in inpatient setting. Below an example for ICD 10 PCS code for root operation excision and resection.
XXBXXXX – ICD 10 PCS code for Excision
XXTXXXX – ICD 10 PCS code for Resection
Read also: Coding tips for Root operation Drainage
Excision and Resection: difference in icd 10 pcs root operations
Resection is coded only when all of the specific body part is removed or cut off. Like, when a particular lung lobe is removed through lobectomy, is coded as resection of lung lobe. While when only a particular small part of the specific body part is removed for exams like biopsy, it is coded as excision. Hope, now you can differentiate when to code resection and excision, the two icd 10 pcs root operations in inpatient coding.
Sample report for icd 10 pcs root operations: Resection
PREOPERATIVE DIAGNOSES: Cholecystitis and cholelithiasis.
POSTOPERATIVE DIAGNOSES: Cholecystitis and cholelithiasis.
PROCEDURE: Laparoscopic cholecystectomy with intraoperative cholangiogram.
ESTIMATED BLOOD LOSS: <5cc
OPERATIVE NOTE: The patient was placed supine on the operative table. After induction of general anesthesia and endotracheal intubation, the patient was prepped and draped in the usual fashion. Time-out was taken. The patient was re-identified and the procedure was verified, and was given pre-operative antibiotics. An infraumbilical incision was made and a 5-mm Optiview trocar was placed without difficulties. The abdomen was insufflated with CO2 until a pressure of 15 mm HG was achieved. The camera was introduced and we inspected the abdominal cavity. The liver was smooth without any nodularities or masses. At this point, we placed two 5 mm ports in the right upper quadrant under direct visualization and an 11-mm port in the epigastric region. We were able to place a grasper on the dome, the other on the infundibulum of the gallbladder. The Triangle of Calot was dissected using lateral retraction of the infundibulum thus exposing this critical angle between the cystic duct and CBD. The peritoneal attachment around the infundibulum of the gallbladder to the liver was dissected free using electrocautery. Thus giving a partial retrograde dissection. This allowed the visualization of the cystic duct and artery as they entered the gallbladder. Having developed this Critical View of Safety at the triangle of Calot we proceeded with our cholangiogram. A Kumar clamp was placed across the body of the gallbladder, the tip of the catheter was inserted into the infundibulum. We then were able to flush this. Using the C-arm fluoroscopy unit, we performed a cholangiogram. In real-time, we saw the passage of contrast throughout the biliary tree, common hepatic, common bile duct, and emptying readily into the duodenum. No filling defects were noted. This was a normal cholangiogram. At this point, the catheter was removed. Clips were placed on the cystic duct and artery and these structures were divided. A PDS loop was placed around the cystic duct stump. We then removed the gallbladder off the liver bed using electrocautery. The liver bed remained completely hemostatic. We removed the gallbladder and placed it into a laparoscopic retrieval bag. We irrigated the operative field and suctioned out the irrigation. We then removed the ports allowing the CO2 to escape. The patient then had the large port site closed at the level of the fascia using #0-Vicryl sutures. The wounds were all irrigated and infiltrated with 0.25% Marcaine. The skin edges were approximated using 4-0 Monocryl and Dermabond. The patient tolerated this well. Sponge, needle, and instrument counts were correct.
ICD 10 PCS code
0FT44ZZ – Resection of Gallbladder, Percutaneous Endoscopic Approach