Root Operations
Putting in a nonbiological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part
What is "Insertion"
Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure.
What is "Open"?
Guideline A10 clarifies that the word "and" can be interpreted as
What is "and/or"?
A single code used to classify two diagnoses, a diagnosis with a secondary condition, or a diagnosis with an associated complication
What is "Combination Code"?
Subjective observation reported by the patient
What is a "symptom"?
Partially closing an orifice or the lumen of a tubular body part
What is "Restriction"
Entry by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure.
What is "Percutaneous Endoscopic"?
The full definition as contained in the in the PCS table must be applied in order to determine this action
What is the "root operation"?
The first coding principle that must be used to locate and assign the appropriate code
What is the "Alphabetic Index" and "Tabular List"?
The seventh character in the code in the Medical and Surgical Section; it carries additional information for that particular procedure
What is the "Qualifier"?
Putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part
What is "Transplantation"?
Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure.
What is "Via Natural or Artificial Opening"?
Guideline B3.3 states if the intended procedure is discontinued or otherwise not completed, the coder should
What is "code the root operation inspection"?
The need for dual coding is indicated by the presence of this code note
What is "use additional code" and/or "code first underlying condition"?
This diagnosis is defined as SIRS due to an infection, a severe case indicates organ dysfunction
What is "Sepsis"?
Cutting into a body part, without draining fluids and/or gases from the body part, in order to separate or transect a body part
What is "Division"?
Procedures performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane
What is "External"?
Biopsy procedures are coded using this qualifier
What is "diagnostic"?
This type of code is never assigned when a more specific code for the same general condition is assigned
"What is "unspecified"?
This diagnosis is characterized as a chronic condition of impaired carbohydrate, protein and fat metabolism. The condition can lead to many complications and involves the failure of the body to produce insulin or to utilize insulin
What is "Diabetes Mellitus"?
Taking or letting out fluids and/or gases from a body part
What is "drainage"?
Entry of instrumentation through a natural or artificial external opening and entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to aid in the performance of the procedure
What is "Via Natural Opening with Percutaneous Endoscopic Assistance?
The body part value corresponding to the furthest anatomical site from the point of entry applies to this section of a body part
What is "tubular"?
A diagnosis described as this is never coded
What is "ruled out"?
A deficiency of platelets, which are important for blood clotting.
What is "Thrombocytopenia"?