Question

Review the case study below and code the correct procedure(s) using ICD-10-PCS. Provide the rationale for your code selection.

PREOPERATIVE DIAGNOSIS:

1. Gangrene right foot.
POSTOPERATIVE DIAGNOSIS:

1. Gangrene right foot.
OPERATION:

1. Right below the knee amputation.
ANESTHESIA:               General LMA.

The patient was brought to the operative suite where a general LMA anesthesia was induced.

A Foley catheter was inserted and the right foot was secluded in an isolation bag and the lright lower extremity circumferentially prepped and draped in its entirety. Beginning on the right side, the skin was marked with a marking pen 4 finger breadths below the tibial tuberosity anteriorly with a long posterior flap. The skin was incised circumferentially and the anterior musculature sharply divided, exposing the tibia. The tibia was cleaned with a periosteal elevator and then transected with the Stryker saw. The fibula was exposed and transected with the bone cutter and the amputation completed by sharply incising the posterior musculature. Bleeding vessels were ligated with 2-0 silk ligature. There appeared to be adequate bleeding at this level for primary healing the tibia was then cleaned with a bone rasp and the fibula with a tongeur. The would was irrigated and ultimately closed without significant tension utilizing interrupted 2-0 vicryl sutures for reapproimation of the fascia and skin staples for reapproimation of the skin.

The right side was dressed with sterile gauze fluff dressing and a Kerlix roll. Estimated blood loss throughout the procedure was approximately 150 ml. The patient received one unit intraoperatively of packed cells because of preoperative anemia. She was transported in stable condition to the recovery room.

**If you do not have a code book, please describe the correct procedures in this case that would be coded**

Answer 1

QUESTION: Review the case study below and code the correct procedure(s) using ICD-10-PCS. Provide the rationale for your code selection.

PREOPERATIVE DIAGNOSIS:

1. Gangrene right foot.
POSTOPERATIVE DIAGNOSIS:

1. Gangrene right foot.
OPERATION:

1. Right below the knee amputation.
ANESTHESIA:               General LMA.

ANSWER:

• The ICD-10-PCS code for the given procedure is 0 Medical and Surgical-B3.8 Resection

ICD-10-PCS is a procedure classification published by the United States for classifying procedures performed in hospital inpatient health care settings.

• 0 Medical and Surgical
• 1 Obstetrics
• 2 Placement
• 3 Administration
• 4 Measurement and Monitoring
• 5 Extracorporeal or Systemic Assistance and Performance
• 6 Extracorporeal or Systemic Therapies
• 7 Osteopathic
• 8 Other Procedures
• 9 Chiropractic
• B Imaging
• C Nuclear Medicine
• D Radiation Therapy
• F Physical Rehabilitation and Diagnostic Audiology
• G Mental Health
• H Substance Abuse Treatment
• X New Technology

Rationale:

B3.8 Resection : Resection of the specific body part is coded whenever all of the body part is cut out or off, rather than coding Excision of a less specific body part.

In the given procedure, right below the knee amputation procedure was done. Since it is a major surgery, it comes under 0 Medical and Surgical.

      As the procedure involves removal of body part( below the knee) (that is transecting the fibula and completing the amputation by sharply incising the posterior musculature) it comes under B3.8 Resection.