A quarterly publication of the

Central Office on ICD-10-CM/PCS

Volume 8 Second Quarter
Number 2 2021
Ask the Editor Peritoneal Dialysis Catheter
Bilateral Chronic and Placement 14
Subsegmental Pulmonary Persistent Atrial Fibrillation,
Embolism 9 Anticoagulant Therapy and
Dorsal Root Entry Zone Acquired versus Inherited
Procedure 17 Hypercoagulable State 8
Electromagnetic Stealth Guided Removal of Peritoneal Dialysis
Ventriculoperitoneal Shunt Catheter 14
Insertion w
ith Endoscopy 19 Repositioning of Displaced
Excision of Pituitary Intra-Aortic B
alloon Pump 12
Macroadenoma within Serosal Injury with Excision
Cavernous Sinus 15 of Small I ntestine 11
Excision of Tibial Sesamoid 18 Static Encephalopathy due to
Ex Utero Intrapartum Treatment Epilepsy 3
Procedure 21 T-Cell Lymphoma of Multiple
Goldilocks Breast Reconstruction 16 and Extranodal Sites 6
Granulomatosis with Polyangiitis 10 Thromboendarterectomy with
Infrarenal Para-Aortic Deconstruction of Internal
Paraganglioma with Excision 7 Carotid A
rtery 13
Major Neurocognitive Disorder Traumatic Subdural and
without Behavioral Subarachnoid Hemorrhage
Disturbance 4 with Loss of Consciousness 5
Malone Antegrade Continence Use of Additional Code for
Enema P rocedure 20 Condition of Unspecified
Multiple Glasgow Coma Scale Type 10
Scores Pre and Post
Admission 4 Clarification
Neurosyphilis with Human Lead Placement in Bundle
Immunodeficiency Virus of His 23
Disease 6
Paroxysmal Atrial Fibrillation, Correction Notice
Anticoagulant Therapy and COVID-19 Infection,
Acquired Hypercoagulable Hydropneumothorax and
State 8 Barotrauma 23

Coding advice or code assignments contained in this issue effective

with discharges June 7, 2021.
Coding Clinic for Medical Advisors, Centers for Edward A. Liechty, M.D.
Medicare & Medicaid Services Representative, American
ICD•10•CM/PCS Academy of Pediatrics,
Published quarterly by the Perry Alexion, M.D.
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Jeffrey F. Linzer, M.D., FAAP
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 Ask the Editor
Question:
A five-year-old female with profound develop-
mental delays and epilepsy has chronic static
encephalopathy secondary to epilepsy and ep-
ileptic encephalopathy. In the Alphabetic Index,
under the main term Encephalopathy there is
no subentry for static. What is the appropriate
ICD-10-CM diagnosis code assignment for
chronic static encephalopathy secondary to
epilepsy and epileptic encephalopathy? Is static
encephalopathy inherent to the epilepsy and
not coded separately?

Answer:
Assign code G93.49, Other encephalopathy, for
chronic static encephalopathy. Assign also code
G40.909 Epilepsy, unspecified, not intractable,
without status epilepticus, for the epilepsy.
Although the static encephalopathy is linked
to the epilepsy, the provider has documented
that it is a chronic condition. Unlike transient
epileptic encephalopathy occurring in the
postictal state, where the patient returns to
baseline, static encephalopathy is a chronic or
permanent condition and is therefore coded
separately.

When encephalopathy is linked to a specific

condition, it is appropriate to use the code
describing “other encephalopathy,” since codes
describing “other” or “other specified” are
for use when the information in the medical

Coding Clinic Second Quarter 2021 3

 record provides detail for which a specific code
does not exist. This is consistent with advice
published in Coding Clinic Second Quarter
2018, pages 24-25.

Question:
What is the appropriate code assignment
for a major neurocognitive disorder without
behavioral disturbance when the underlying
etiology is unknown, or not further specified?
Depending on how the Alphabetic Index is
referenced, the coding professional may arrive
at different code assignments, F03.90 versus
F01.50.

Answer:
Assign code F03.90, Unspecified dementia
without behavioral disturbance, for a major
neurocognitive disorder, when the underlying
condition is unknown or not further specified.
Although “Major neurocognitive disorder
without behavioral disturbance” is an inclusion
term under code F01.50, Vascular dementia
without behavioral disturbance, in this case,
the etiology is unknown. Therefore, it would not
be appropriate to assign a code for vascular
dementia.

Question:
The Glasgow coma scale (GCS) is used to help
evaluate the acuity of traumatic brain injuries.
Therefore, would it be appropriate to report the
most severe GCS score if the patient’s score
worsens after admission, but within the first 24
hours?

Answer:
ICD-10-CM does not classify scores that are
reported after admission but less than 24
hours later. Therefore, only assign one code
that represents the GCS score at the time of
admission with a POA of “Y.”

4 Second Quarter 2021 Coding Clinic

 Question:
A patient with traumatic subarachnoid
hemorrhage and traumatic subdural
hemorrhage due to a fall was initially noted
to have loss of consciousness (LOC), for
approximately 30 minutes at the time of injury
at home. Upon admission, the patient was
awake, alert and oriented, but his neurological
status declined and he became unresponsive
and comatose for over 24 hours without
regaining consciousness. He was discharged
to a long-term care hospital for continued care.
What seventh character is assigned for the
LOC (e.g., the initial LOC at the time of the
injury or the longest duration)? Additionally,
what is the appropriate present on admission
indicator (POA) for the traumatic brain
hemorrhages with LOC?

Answer:
Assign codes S06.6X6A, Traumatic
subarachnoid hemorrhage with loss of
consciousness greater than 24 hours without
return to pre-existing conscious level with
patient surviving, initial encounter, S06.5X6A,
Traumatic subdural hemorrhage with loss of
consciousness greater than 24 hours without
return to pre-existing conscious level with
patient surviving, initial encounter, and R40.20,
Unspecified coma. Additionally, assign codes
W19.XXXA, Unspecified fall, initial encounter,
and Y92.009, Unspecified place in unspecified
non-institutional (private) residence as the
place of occurrence of the external cause.

Loss of consciousness of the longest duration

should be reported. Assign POA indicator “Y,”
for the traumatic subarachnoid and subdural
hemorrhage, as the injury was present on
admission, and loss of consciousness is part of
the disease process.

Coding Clinic Second Quarter 2021 5

 Question:
A 50-year-old patient with a history of human
immunodeficiency virus (HIV) disease
presented after experiencing blurry vision for
the past two weeks. The patient was admitted
and after work-up, the provider diagnosed
neurosyphilis. There is an Excludes1 note,
at categories A50-A64, Infections with a
predominantly sexual mode of transmission,
excluding code B20, Human immunodeficiency
virus [HIV] disease. The provider was queried
whether the neurosyphilis was due to the
patient’s HIV infection and the provider did
not respond. If code B20 were assigned as
directed by the Excludes1 note, the reason for
the patient’s admission, neurosyphilis would not
be captured. What are the appropriate code
assignments for this admission?

Answer:
It would be appropriate to assign codes A52.3,
Neurosyphilis, unspecified, and B20, Human
immunodeficiency virus [HIV] disease. Both
codes are needed to fully capture the patient’s
conditions. In this instance, the provider did not
link the conditions, therefore it is appropriate to
bypass the Excludes1 note, because they are
considered unrelated and separate conditions.

Question:
A patient with a history of T-cell lymphoma of
the skin presented due to fever, hypotension
and worsening skin lesions. A positron emission
tomography (PET) scan was performed which
showed multiple metabolically active lesions.
The provider diagnosed the patient with
recurrent T-cell lymphoma involving multiple
lymph nodes above and below the diaphragm,
as well as active lesions in the spleen and skin.
Would multiple codes be assigned to capture
each site involved? What are the appropriate
code assignments for this admission?

6 Second Quarter 2021 Coding Clinic

 Answer:
Assign codes C84.A8, Cutaneous T-cell
lymphoma, unspecified, lymph nodes of
multiple sites, and C84.A7, Cutaneous T-cell
lymphoma, unspecified, spleen, to capture
cutaneous T-cell lymphoma of multiple lymph
nodes, as well as the spleen. The skin lesions
are inherent to cutaneous T-cell lymphoma.

Question:
A patient with a known history of a carotid body
tumor is admitted for surgical treatment of a
left infrarenal para-aortic mass consistent with
a paraganglioma. During the procedure, an
incision was made in the midline above and
below the umbilicus. The peritoneal cavity was
entered and the mass was found to be adjacent
to the aorta and inferior to the left renal hilum.
The mass was removed, the midline fascia
was closed and the deep subcutaneous tissue
was reapproximated. What is the ICD-10-CM
diagnosis code for an infrarenal para-aortic
paraganglioma? What is the appropriate ICD-
10-PCS code for excision of infrarenal para-
aortic paraganglioma?

Answer:
Assign code D44.7, Neoplasm of uncertain
behavior of aortic body and other paraganglia,
for infrarenal para-aortic paraganglioma.

Assign the following procedure code:

0GB90ZZ Excision of para-aortic body,

open approach, for excision of
infrarenal para-aortic
paraganglioma (mass).

Coding Clinic Second Quarter 2021 7

 Question:
A 79-year-old patient is diagnosed with
secondary hypercoagulable state and has a
history of paroxysmal atrial fibrillation (AF) on
anticoagulant maintenance. Does the provider
need to link the secondary hypercoagulable
state with the atrial fibrillation? What is the
appropriate ICD-10-CM code assignment
for secondary hypercoagulable state in this
scenario?

Answer:
Assign code D68.69, Other thrombophilia,
for secondary hypercoagulable state.
Secondary hypercoagulable state is specifically
indexed to this code and includes secondary
hypercoagulable state NOS.

Secondary hypercoagulable states are acquired

disorders of thrombosis due to complex and
multifactorial mechanisms. Patients with
AF on chronic anticoagulant therapy may
have an increased incidence of acquired
hypercoagulable state. However, unless
specifically documented by the provider, coding
professionals should not assume the presence
of a secondary (acquired) hypercoagulable
state, in patients with atrial fibrillation. In this
case, although the provider did not link the
hypercoagulable state to the atrial fibrillation,
secondary hypercoagulable state was
documented by the provider.

Question:
A 76-year-old male with persistent atrial
fibrillation (AF) on anticoagulant therapy
presented for follow-up. The provider listed
“Hypercoagulable state” in the diagnostic
statement. However, he also noted, “No
Hematological/Immunologic disorder,” in the
History and Physical Exam. Code D68.59,
Other primary thrombophilia, is the default

8 Second Quarter 2021 Coding Clinic

 code assignment for hypercoagulable state.
However, code D68.59 identifies an inherited
coagulation abnormality. In researching the
condition, we found out that patients with AF
on anticoagulant therapy might develop a
secondary hypercoagulable state. How should
a hypercoagulable state be coded when the
provider does not indicate whether it is an
acquired or inherited condition?

Answer:
Query the provider for clarification as
to whether the patient has an acquired
hypercoagulable state. Code D68.59, Other
primary thrombophilia, is used for primary/
inherited hypercoagulable state, and the
documentation does not appear to support this
diagnosis.

AF treated with anticoagulants may be

associated with an increased incidence of
acquired hypercoagulable state. However, if the
documentation is unclear, query the provider
for clarification, so the appropriate code can be
reported.

Question:
The patient was diagnosed with chronic
bilateral subsegmental pulmonary emboli
(PE). In the Alphabetic Index under Embolism,
pulmonary, there are separate subentries at
the same indentation level for chronic and
multiple subsegmental. Coding Clinic Fourth
Quarter 2019, page 7, appears to imply
that it is more important to capture that the
emboli are subsegmental as this is important
clinical information. What is the correct code
assignment for chronic bilateral subsegmental
pulmonary emboli?

Coding Clinic Second Quarter 2021 9

 Answer:
Assign codes I26.94, Multiple subsegmental
pulmonary emboli without acute cor pulmonale,
and I27.82, Chronic pulmonary embolism,
for bilateral chronic subsegmental pulmonary
emboli. Both codes are needed to fully describe
the patient’s condition and the Excludes 2 note
at category I26, Pulmonary embolism, indicates
it is acceptable to use both codes when
appropriate.

Question:
What is the appropriate ICD-10-CM code
for granulomatosis with polyangiitis, without
documented Wegener’s granulomatosis?

Answer:
Assign code M31.30, Wegener’s
granulomatosis without renal involvement,
for granulomatosis with polyangiitis.
Granulomatosis with polyangiitis is a rare
condition that is categorized as a specific
type of vasculitis. The condition can cause
inflammation of the blood vessels in the sinus
tract, throat, lungs and kidneys, resulting in
decreased blood flow and granulomas in the
affected areas. This condition was previously
referred to as Wegener’s granulomatosis.

Question:
An obese woman, who is 40 weeks gestation,
had a normal delivery of a healthy infant. The
provider noted “Obesity” in his final diagnostic
statement. There is a note in the Tabular List
instructing, “Use additional code to identify the
type of obesity (E66.-)” under code O99.214,
Obesity complicating childbirth. Since the
type of obesity is not specified, would it be
appropriate to only assign code O99.214,
Obesity complicating childbirth, since code
E66.9, Obesity, unspecified, does not describe
a type of obesity?

10 Second Quarter 2021 Coding Clinic

 Answer:
Facilities may develop internal facility-specific
coding policies, stipulating whether to report
“unspecified” codes as additional codes, when
more specific information is not documented
and the unspecified code does not add any
useful information. Any internal facility-specific
coding policies developed must be applied
consistently to all health records coded.

For example, code O99.214, Obesity

complicating childbirth, fully captures the
diagnostic statement. Therefore, code E66.9,
Obesity, unspecified, would not be needed
as an additional code assignment, because
“unspecified” is not a type of obesity and
code E66.9 does not provide any additional
information.

Question:
During a laparoscopic salpingo-oophorectomy,
the surgeon noted an incarcerated loop of
small bowel adherent to a ventral hernia sac.
After take down, the bowel was discolored
with multiple serosal tears. The incision was
then extended, the loop of bowel was brought
out through the incision and the segment
with the serosal injury was excised. It seems
that serosal tears requiring excision would be
clinically significant. However, in this case, the
provider documented the injury was inherent
to the nature of the procedure. On query, he
stated the serosal tear was “Unavoidable during
extensive lysis of adhesions, not intraoperative
complication.” Would any bowel injury requiring
excision be considered clinically significant and
reportable? How is the serosal injury and repair
by excising the small intestine coded?

Coding Clinic Second Quarter 2021 11

 Answer:
Assign code K91.71, Accidental puncture
and laceration of a digestive system organ or
structure during a digestive system procedure,
for the serosal injury of the small intestine.
Although after query the provider indicated the
serosal tear was unavoidable, it was clinically
significant, as it required further excision,
complicating the surgery. Therefore, the
excision of the small intestine is coded. Assign
the following procedure code:

0DB80ZZ Excision of small intestine, open

approach, for the excision of the
small intestine.

Question:
The patient presented for repositioning of
his intra-aortic balloon pump (IABP) due to
distal migration of the catheter. In the cath lab,
the balloon catheter was repositioned under
fluoroscopic guidance by advancing the tip of
the catheter to the aortic knob. Fluoroscopic
examination following the repositioning
revealed proper positioning of the balloon pump
catheter. How should we report repositioning of
an IABP?

Answer:
Assign the following ICD-10-PCS code:

5A02210 Assistance with cardiac output

using balloon pump, continuous,
for the continued IABP
assistance.

Since an IABP is not classified as a device

in ICD-10-PCS, repositioning would not be
coded separately from the IABP assistance.
The fluoroscopic guidance may also be coded,
if desired. For additional discussion of IABP
assistance, see Coding Clinic Second Quarter
2018, pages 3-5.

12 Second Quarter 2021 Coding Clinic

 Question:
A patient with stenosis of the left cervical
internal carotid artery (ICA) and left
hemispheric embolic stroke underwent left-
sided thromboendarterectomy. At surgery,
an arteriotomy was started from the common
carotid artery and extended up into the highest
exposed portion of the ICA. A large fragment of
thrombotic calcific plaque including intraluminal
thrombus was removed. As the distal extent
of this plaque material was followed within the
ICA, there was no end that could be visualized,
and there was no robust backbleeding. The
surgeon felt that it would be too risky to
reconstitute the antegrade flow. After allowing
for backbleeding from the external carotid
artery (ECA), the surgeon then deconstructed
the proximal ICA, utilizing suture material.
Clamps were removed from the common
carotid and ECA, allowing for egress of flow
from the common carotid to the external and
superior thyroid artery. There was no flow into
the ICA. What are the appropriate ICD-10- PCS
codes for this procedure?

Answer:
Assign the following ICD-10-PCS codes:

03CL0ZZ Extirpation of matter from the left

internal carotid artery, open
approach, for the thrombectomy;
and

03LL0ZZ Occlusion of the left internal

carotid artery, open approach,
for the deconstruction.

Since it was determined that the artery could

not be reopened by the endarterectomy, the
surgeon deconstructed the internal carotid
artery to occlude flow permanently.

Coding Clinic Second Quarter 2021 13

 Question:
A patient was admitted due to mental status
decline and required placement of a peritoneal
dialysis catheter during the admission because
of end-stage renal disease. At surgery, a
vertical incision was made lateral to the
umbilicus on the left side of the abdomen.
Dissection was carried down to the anterior
fascia and the anterior fascia was incised.
The rectus muscle was dissected to expose
the posterior fascia. A purse-string suture was
then made around the posterior fascia, and a
small nick was made in the posterior fascia. A
peritoneal dialysis catheter was inserted in the
direction of the lower pelvis and then secured
to the purse-string suture and the anterior
fascia was closed. The dialysis catheter was
tested and then tunneled exiting out the skin
just below the level of the umbilicus. What
is the appropriate ICD-10-PCS code for this
procedure? Would the correct approach value
be open or percutaneous?

Answer:
Assign the following ICD-10-PCS code:

0WHG03Z Insertion of infusion device

into peritoneal cavity, open
approach, for the placement of
peritoneal dialysis catheter.

In this case, the approach value is Open,

because an incision was made and extended
and the rectus muscle was dissected to expose
the posterior fascia.

Question:
A patient with end-stage renal disease
presented for removal of his peritoneal dialysis
catheter, because of concern for peritonitis.
During the removal procedure, the previous
periumbilical scar was incised down to the

14 Second Quarter 2021 Coding Clinic

 fascia. The catheter was followed through the
fascia and the peritoneal cuff was identified
and dissected free. When the intraperitoneal
portion of the catheter was removed, there was
direct visualization of the undersurface of the
fascia, as well as omentum and small bowel.
The catheter was cut and the intraperitoneal
portion of the catheter was passed off the table.
The subcutaneous portion of the catheter was
then easily removed. What is the appropriate
approach value for removal of the peritoneal
dialysis catheter?

Answer:
The catheter was removed under direct
visualization. Assign the approach value, “0”
Open for the catheter removal. In this case, an
incision was made through the scar and down
to the fascia. The peritoneal cuff was visualized
and dissected free.

Question:
The patient was admitted for surgical excision
of a pituitary macroadenoma within the
cavernous sinus. A left pterional incision was
made and dissection was carried down to the
dura and zygomatic osteotomy, which allowed
excellent exposure of the anterior middle fossa.
Attention was then turned to the anterior middle
fossa and the lateral cavernous sinus. There
was a small area where tumor had eroded
through the dura and this area was quite boggy
consistent with cavernous sinus involvement.
The small tumor breach allowed the provider
to enter the cavernous sinus, which was
widely opened. The tumor cavity was entered
and the tumor was removed with suction and
with ring curettes. What is the appropriate
ICD-10-PCS code for excision of the pituitary
macroadenoma within the cavernous sinus?

Coding Clinic Second Quarter 2021 15

 Answer:
Assign the following procedure code:

05BL0ZZ Excision of intracranial vein,

open approach, for the excision
of the cavernous sinus tumor.

The cavernous sinus is a dural venous sinus

located within the brain. The ICD-10-PCS body
part key under “dural venous sinus” directs the
coding professional to use “intracranial vein.”

Question:
The patient is a 62-year-old female with breast
carcinoma and asymmetry, who presents
for bilateral skin-sparing mastectomy with
“Goldilocks” breast reconstruction. At surgery,
the right breast was incised; long random-
pattern flaps were raised and preserved. The
breast was then elevated off the underlying
pectoralis major muscle en bloc with the
pectoralis major muscle fascia. Attention
was then directed to the left side where an
identical procedure was performed. Following
mastectomy, plastic surgery examined the
mastectomy flaps and proceeded with the
“Goldilocks” procedure. De-epithelialization of
the inferior pole skin was done. This was folded
onto itself and sutured in place in the standard
fashion. This was performed bilaterally.
The skin incisions were brought together in
layers. What is the correct root operation for a
“Goldilocks” breast reconstruction?

Answer:
Assign the following ICD-10-PCS codes:

0HTV0ZZ Resection of bilateral breast,

open approach, for the skin-
sparing mastectomies of the
right and left breasts;

16 Second Quarter 2021 Coding Clinic

 0JX60ZB Transfer chest subcutaneous
tissue and fascia with skin and
subcutaneous tissue, open
approach, for the “Goldilocks”
right breast reconstruction; and

0JX60ZB Transfer chest subcutaneous

tissue and fascia with skin and
subcutaneous tissue, open
approach, for the “Goldilocks”
left breast reconstruction.

In this case, skin and subcutaneous tissue is

moved to take over a portion of the function
of the breast. The vascular supply is still
connected. This surgery meets the definition
of the root operation Transfer: Moving, without
taking out, all or a portion of a body part to
another location to take over the function of all
or a portion of a body part.

For a mastectomy with reconstruction, it is

important to identify that the primary objective
of the surgery is to remove cancerous or
potentially cancerous breast tissue, and
note that the reconstruction is an additional
objective (ICD-10-PCS Guideline B3.1b.). The
reconstruction procedure is coded the same
whether it is performed at the same time as the
mastectomy or as a separate procedure.

Question:
A patient with left cervical pain due to dorsal
root avulsion underwent surgical treatment.
Following exposure of the C6-T2 spinous
processes, a laminectomy was performed
and a microscope was used for microscopic
dissection. A microscope was then used to
open the arachnoid, and dorsal root entry zone
(DREZ) lesions were made between the T1 and
C7 rootlets. What is the appropriate procedure
code for this DREZ procedure?

Coding Clinic Second Quarter 2021 17

 Answer:
Assign the following ICD-10-PCS codes:

005W0ZZ Destruction of cervical spinal

cord, open approach; and

005X0ZZ Destruction of thoracic spinal

cord, open approach, for the
creation of dorsal root entry zone
lesions between the T1 and C7
rootlets.

The dorsal root ganglion is considered part of

the spinal cord.

Question:
A patient presents for excision of the right tibial
sesamoid bone secondary to osteomyelitis.
During surgery, an incision was made medial
to the first metatarsal. After dissection, the
ligaments and soft tissue surrounding the tibial
sesamoid were cut in order to excise the bone.
The soft and discolored sesamoid was removed
and sent to pathology. Is the sesamoid
considered a separate bone and coded to the
root operation Resection? Conversely, is the
tibial sesamoid an extension of the metatarsal
and coded to the root operation Excision? What
is the appropriate body part value? How is a
tibial sesamoidectomy coded?

Answer:
Assign the following ICD-10-PCS code:

0QBN0ZZ Excision of right metatarsal,

open approach, for the sesamoid
bone removal.

The tibial sesamoid refers to the anatomical

location of the sesamoid bone on the medial
side of the metatarsal area of the foot (as
opposed to the fibular sesamoid bone on the

18 Second Quarter 2021 Coding Clinic

 lateral side). Additionally, this surgery meets
the definition of the root operation Excision:
Cutting out or off, without replacement, a
portion of a body part. A code for resection
of right metatarsal is not assigned since the
entire metatarsal was not removed and the
full definition of the root operation Resection
cannot be applied.

Question:
A patient with hydrocephalus underwent
electromagnetic stealth guided placement of
a right ventriculoperitoneal shunt. Following
the passing of the distal shunt passer and
distal catheter to the abdominal incision,
and placement of a burr hole in the dura, an
electromagnetic stealth was utilized to pass
the proximal catheter to target. An endoscope
was used to confirm the location of the
ventricular portion of the shunt. Laparoscopy
confirmed the placement of the distal catheter
in the peritoneum. What are the correct
code assignments for this procedure? Is it
appropriate to report separate codes with
Inspection for the intracranial endoscopy and
laparoscopy?

Answer:
Assign the following procedure codes:

00163J6 Bypass cerebral ventricle

to peritoneal cavity with synthetic
substitute, percutaneous
approach, for the
ventriculoperitoneal shunt
placement;

00J04ZZ Inspection of brain,

percutaneous endoscopic
approach, for the endoscopy to
confirm intraventricular location;

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 0WJG4ZZ Inspection of peritoneal cavity,
percutaneous endoscopic
approach, for the laparoscopy to
confirm catheter placement; and

8E09XBZ Computer assisted procedure of

head and neck region, for the
electromagnetic stealth
guidance.

In this case, the Inspection procedures are

coded separately because they both used a
different approach from the Bypass procedure.
The ICD-10-PCS Official Guidelines for
Coding and Reporting (B3.11c) regarding
inspection procedures and another procedure
on the same body part state, “When both an
Inspection procedure and another procedure
are performed on the same body part during
the same episode, if the Inspection procedure
is performed using a different approach than
the other procedure, the Inspection procedure
is coded separately.

Question:
The patient is a 12-year-old male with a
longstanding history of chronic constipation,
who is admitted to undergo Malone Antegrade
Continence Enema (MACE) procedure. During
the procedure, a normal appearing appendix
was identified. After adequate mobilization,
in an open fashion, the appendix and cecum
were delivered through the wound and isolated.
The tip of the appendix was dissected off and
sutures were used for plication of the appendix
to the cecum. The base of the appendix and
cecum were then secured to the fascia at the
level of the umbilicus. The appendix was cut
to length so that only a small cusp remained
above the level of the skin. This was sewn
around the skin in order to fix the superior
portion of the appendicostomy to the skin. How
is the MACE procedure coded in ICD-10-PCS?

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 Answer:
Assign the following procedure code:

0DUE07Z Supplement large intestine with

autologous tissue substitute,
open approach.

In this case, the objective of the surgery

is to repurpose the appendix to serve as
a catheterizable channel to the bowel for
the administration of enemas to produce
normal bowel movements. By managing the
constipation, the patient’s large intestine can
continue to function normally. The surgery
involves connecting the appendix to the
umbilicus and creating a valve mechanism
by plicating the cecum around the appendix.
The procedure enables catheterization of the
appendix for the infusion of enema fluid into the
intestine.

Question:
A pregnant patient presents at 38 weeks
because the fetus was found to have a left
upper lobe lung mass. The mother underwent
the ex utero intrapartum (EXIT) procedure,
in which the mass on the fetus’ lung was
excised via low transverse hysterotomy. The
head, neck, upper extremities and upper
torso of the fetus were delivered through
low transverse hysterotomy. The surgeon
performed the thoracotomy and excision of
the fetal lung mass while the fetus was still
attached to the umbilical cord and placenta.
The fetal thoracotomy was closed, and the
lower torso and lower extremities of the fetus
were delivered through the hysterotomy.
The umbilical cord was then cut, and the
infant was handed off to the surgical team for
further stabilization/resuscitation. What is the
appropriate procedure code assignment for the
EXIT procedure to remove the mass from the
fetal lung?

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 Answer:
On the mother’s record, assign the following
ICD-10-PCS code:

10Q00ZK Repair respiratory system in

products of conception, open
approach, for the removal of the
lung lesion/mass from the fetus,
in addition to the code for the
cesarean section.

Since the fetus was not completely ex utero, a

code is not reported on the baby’s record for
the EXIT procedure, as it was performed on
products of conception.

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 Clarification
Clarification of Lead Placement in
Bundle of His

Coding Clinic’s goal is to provide advice

consistent with ICD-10-CM and ICD-10-PCS
guidelines and conventions that is based on
specific case examples submitted to the AHA
Central Office. When applying this advice
in real world scenarios, code assignment
should be based on the documentation in
the medical record. The advice previously
published in Coding Clinic Third Quarter 2019
about placement of a lead in the bundle of
His was specific to that case, as the lead was
documented as having been placed in the left
ventricle. Bundle of His lead placement may
be approached from the left or right. In coding
the placement of bundle of His leads, coding
professionals should identify whether lead
placement is through a left or right approach.
If the health record documentation is unclear,
query the provider.

Correction Notice
COVID-19 Infection, Hydropneumothorax
and Barotrauma

The Q&A published in Coding Clinic First

Quarter 2021, page 48 involving COVID-19
infection, hydropneumothorax, barotrauma and
mechanical ventilation contained an omission.
Code J80, Acute respiratory distress syndrome,
was not included in the answer and should
have been assigned for the ARDS.

Coding Clinic Second Quarter 2021 23

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