The scenario describes a patient undergoing a laparoscopic cholecystectomy with intraoperative cholangiogram and choledocholithotomy. The primary procedure is the laparoscopic cholecystectomy. The intraoperative cholangiogram is a diagnostic procedure performed during the cholecystectomy to visualize the bile ducts. The choledocholithotomy is a therapeutic procedure to remove stones from the common bile duct. In ICD-10-PCS, the root operation for removing something from a body part is “Excision” if a portion is removed, or “Extraction” if the entire object is removed. Since stones are being removed from the common bile duct, “Extraction” is the appropriate root operation. The body part is the common bile duct. The approach is percutaneous, as the cholangiogram and stone removal are performed through a scope inserted via a small incision. The device used for extraction is typically a scope or catheter, which falls under the “Mechanical or Endoscopic Device” qualifier. Therefore, the ICD-10-PCS code for the choledocholithotomy would involve the root operation Extraction, the body part Common Bile Duct, the approach Percutaneous, and the device Mechanical or Endoscopic Device. The explanation focuses on the correct identification of root operations, body parts, approaches, and devices within the ICD-10-PCS system for complex surgical scenarios, emphasizing the distinction between diagnostic and therapeutic interventions and their respective coding implications. This aligns with the rigorous application of coding guidelines required at Certified Coding Specialist (CCS) University, where understanding the nuances of procedure coding is paramount for accurate data capture and reimbursement. The ability to dissect a complex operative report into its constituent components and map them to the appropriate ICD-10-PCS codes demonstrates a critical thinking skill essential for success in advanced health information management.

The scenario describes a patient undergoing a complex surgical procedure involving the removal of a malignant neoplasm from the ascending colon, with concurrent creation of a colostomy and lysis of adhesions. In ICD-10-PCS, the root operation for cutting out tissue is “Excision.” The anatomical location is the ascending colon. The creation of a colostomy is a separate procedure, a “Diversion” root operation, specifically a “Change” to create a new opening. Lysis of adhesions is also a distinct procedure, a “Release” root operation. For the primary procedure (neoplasm removal), the root operation is Excision. The body part is Ascending Colon. The approach is Open. The device is None. The qualifier is Malignant Neoplasm. This leads to a PCS code that reflects the excision of the ascending colon. For the colostomy creation, the root operation is Change. The body part is Large Intestine, which is the general category for the colon. The approach is Open. The device is Ostomy, and the qualifier is Colostomy. This leads to a PCS code for the colostomy. For the lysis of adhesions, the root operation is Release. The body part is Peritoneum, as adhesions are typically lysed from the peritoneal lining. The approach is Open. The device is None. The qualifier is Adhesions. This leads to a PCS code for the release of adhesions. Therefore, the correct coding approach involves identifying the distinct root operations, body parts, approaches, devices, and qualifiers for each component of the surgical encounter as per ICD-10-PCS guidelines. The final coding sequence would reflect the principal procedure first, followed by secondary procedures. The question asks for the most accurate representation of the *entire* surgical encounter, implying the need to capture all distinct procedures performed. The correct option accurately reflects these distinct ICD-10-PCS root operations and body part values for each surgical component.

The scenario describes a patient undergoing a complex surgical procedure involving the removal of a malignant neoplasm from the ascending colon, with a concurrent creation of a colostomy and a partial colectomy. The primary diagnosis is malignant neoplasm of the ascending colon. The surgical procedure involves a partial colectomy of the ascending colon, which is a resection of a portion of the colon. The creation of a colostomy is a separate procedure, often referred to as an ostomy or stoma creation. In ICD-10-PCS, the root operation for removing part of a body organ is “Resection.” For the ascending colon, the body part value would be “Colon, Ascending.” The approach for this open procedure is “Open.” Therefore, the PCS code for the resection of the ascending colon is 0DUB0ZZ. The creation of a colostomy involves diverting the contents of the intestine to an external opening. The root operation for this is “Diversion.” The body part for a colostomy is “Colon.” The approach is “Open.” Therefore, the PCS code for the creation of a colostomy is 0D1F0ZZ. When multiple procedures are performed, the principal procedure is the one most responsible for the patient’s admission. In this case, the resection of the malignant neoplasm is the principal procedure. However, the question asks for the coding of the *entire* encounter, implying all significant procedures. The ICD-10-PCS guidelines state that when a colostomy is created as part of a colectomy, the colostomy creation is coded separately. Therefore, both procedures should be coded. The correct combination of PCS codes for the resection of the ascending colon and the creation of a colostomy, given the malignant neoplasm as the principal diagnosis, would involve the root operation of Resection for the colon and Diversion for the colostomy. The specific ICD-10-PCS codes are derived by identifying the correct root operation, body part, approach, and device/qualifier. For the resection of the ascending colon, it is 0DUB0ZZ (Resection of colon, ascending, open approach, no device). For the creation of a colostomy, it is 0D1F0ZZ (Diversion of colon, open approach, no device). The question asks for the most appropriate coding representation of the encounter, considering the primary diagnosis and the procedures performed. The correct coding approach involves identifying the principal procedure and any other significant procedures. The malignant neoplasm of the ascending colon drives the admission, making the resection of the ascending colon the principal procedure. The creation of the colostomy is a significant secondary procedure. Therefore, the combination of codes representing these distinct actions is crucial. The correct coding would reflect the resection of the ascending colon and the creation of the colostomy.

The scenario describes a patient undergoing a laparoscopic cholecystectomy with intraoperative cholangiogram and exploration of the common bile duct. The key to accurately coding this procedure lies in understanding the ICD-10-PCS root operations and body system. The principal procedure is the laparoscopic cholecystectomy, which involves cutting out the gallbladder. The root operation for cutting out is “Excision.” The body part is the gallbladder, which falls under the Hepatobiliary System and Pancreas body system. Therefore, the root operation is Excision, and the body part is the Gallbladder. The approach is laparoscopic, which is a percutaneous approach. The device is none, and the qualifier is none. This leads to the ICD-10-PCS code for laparoscopic cholecystectomy. The intraoperative cholangiogram is a diagnostic imaging procedure performed during the cholecystectomy. In ICD-10-PCS, diagnostic imaging of a body part is coded under the root operation “Imaging.” The body part is the common bile duct, which is part of the Hepatobiliary System and Pancreas body system. The approach is the same as the cholecystectomy, which is percutaneous. The device is contrast media, and the qualifier is fluoroscopy. This leads to the ICD-10-PCS code for the cholangiogram. The exploration of the common bile duct is a therapeutic procedure to remove stones or other obstructions. The root operation for removing something from a body part is “Extraction.” The body part is the common bile duct. The approach is again percutaneous, and the device is none. The qualifier is “Stones” if stones were removed, or it could be left as none if the exploration was for other reasons or if the documentation doesn’t specify the nature of the obstruction. Assuming stones were the reason for exploration, the code reflects extraction of stones from the common bile duct. Therefore, the correct coding sequence requires identifying the principal procedure and any additional procedures performed, applying the appropriate root operations, body parts, approaches, devices, and qualifiers based on the ICD-10-PCS guidelines. The question tests the ability to dissect a complex operative report into its component procedures and translate them into accurate ICD-10-PCS codes, demonstrating a nuanced understanding of root operations and body system classifications within the ICD-10-PCS framework, which is a core competency for a Certified Coding Specialist at Certified Coding Specialist University.

The scenario describes a patient undergoing a complex surgical procedure involving the removal of a malignant neoplasm from the sigmoid colon. The operative report details the creation of a primary anastomosis between the descending colon and the rectum. This procedure, involving the transection of the colon and rectum and their subsequent rejoining, is categorized under the root operation of “Bypass” in ICD-10-PCS when the intent is to reroute bodily fluids or energy. However, the direct rejoining of two segments of the same continuous body part, after a portion has been removed, is more accurately classified under the root operation of “Resection” followed by “Reattachment” or, more precisely, “Reconstruction” if a graft or other material is used. Given the direct anastomosis without mention of a graft or diversion, the most appropriate root operation for the rejoining of the colon and rectum segments is “Reconstruction.” Specifically, the procedure involves the body part “Colon,” the body system “Gastrointestinal System,” and the root operation “Reconstruction.” The approach is “Open,” and no device is mentioned. The qualifier “Primary Anastomosis” further clarifies the nature of the reconstruction. Therefore, the correct ICD-10-PCS code would reflect these elements.

The scenario describes a patient undergoing a complex surgical procedure involving the removal of a malignant neoplasm from the ascending colon and a concurrent cholecystectomy. The primary diagnosis is malignant neoplasm of the ascending colon. The ascending colon is part of the large intestine, specifically the proximal part of the large intestine. In ICD-10-CM, the anatomical location of the neoplasm dictates the primary code. Malignant neoplasms of the colon are found in Chapter 2 (Neoplasms). The ascending colon falls under the category for malignant neoplasm of the colon, excluding the cecum and sigmoid colon. Specifically, C18.2 is for Malignant neoplasm of ascending colon. The cholecystectomy, the removal of the gallbladder, is a secondary procedure. The diagnosis for the cholecystectomy is cholelithiasis (gallstones), which is a common indication for this procedure. In ICD-10-CM, cholelithiasis is coded as K80.20 (Calculus of gallbladder without cholecystitis, unspecified as to obstruction). The question asks for the principal diagnosis. The principal diagnosis is defined as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for inpatient hospital services. In this case, the malignant neoplasm of the ascending colon is the primary reason for the admission and the most significant condition requiring treatment, thus it is the principal diagnosis. Therefore, the correct ICD-10-CM code for the principal diagnosis is C18.2.

The scenario describes a patient undergoing a complex surgical procedure involving the removal of a malignant neoplasm from the sigmoid colon, with a concurrent creation of a colostomy. The primary diagnosis is malignant neoplasm of the sigmoid colon. The procedure involves a partial colectomy with anastomosis and the creation of a colostomy. In ICD-10-CM, the principal diagnosis for a malignant neoplasm of the sigmoid colon would be C18.7. For ICD-10-PCS, the coding requires identifying the root operation, body part, approach, and device. 1. **Root Operation:** The removal of the sigmoid colon with anastomosis is a resection. However, the creation of a colostomy is a separate objective. The most appropriate root operation for creating a colostomy is “Detachment” as it involves separating a portion of the intestine to create an external opening. 2. **Body Part:** The sigmoid colon is part of the large intestine. In ICD-10-PCS, the body part for the sigmoid colon is “Large Intestine.” 3. **Approach:** The surgery is described as an open procedure, implying an “Open” approach. 4. **Device:** A colostomy involves creating an opening, but no specific device is implanted in the sense of a prosthesis or graft. Therefore, the device character would be “None.” 5. **Qualifier:** For a colostomy, the qualifier specifies the type of stoma. In this case, it’s a “Colostomy.” Therefore, the ICD-10-PCS code for the creation of a colostomy would be 0D1G0ZZ. The question asks for the most appropriate ICD-10-CM code for the principal diagnosis and the ICD-10-PCS code for the creation of the colostomy. The explanation focuses on identifying the correct codes based on the provided clinical information and the structure of the ICD-10-CM and ICD-10-PCS coding systems. The correct ICD-10-CM code for malignant neoplasm of the sigmoid colon is C18.7. The correct ICD-10-PCS code for creating a colostomy from the large intestine via an open approach is 0D1G0ZZ. The question tests the ability to translate clinical documentation into accurate diagnostic and procedural codes, a core competency for a Certified Coding Specialist at Certified Coding Specialist University. It requires understanding the nuances of neoplasm coding in ICD-10-CM and the detailed structure of ICD-10-PCS, including root operations, body parts, approaches, and qualifiers. The explanation highlights the systematic approach to PCS coding, emphasizing the selection of the most precise terms to represent the performed procedure, which is crucial for accurate reimbursement and data analysis, aligning with the rigorous academic standards at Certified Coding Specialist University.

The scenario describes a patient undergoing a complex surgical procedure involving the removal of a malignant neoplasm from the ascending colon, with a concurrent creation of a colostomy. The primary procedure is a hemicolectomy with creation of an end colostomy. In ICD-10-PCS, the root operation for removing a portion of a body part is “Resection.” The body part is the “Ascending Colon.” The approach is “Open” as it is a surgical procedure. The device is “Ostomy” for the colostomy. The qualifier is “End” to specify the type of ostomy. Therefore, the PCS code for the hemicolectomy with end colostomy would be structured as follows: Section (Medical and Surgical – 0), Body System (Gastrointestinal System – F), Root Operation (Resection – T), Body Part (Ascending Colon – 05), Approach (Open – 0), Device (Ostomy – 0), Qualifier (End – 0). This leads to the PCS code 0FT00Z0. The diagnosis of malignant neoplasm of the ascending colon is coded using ICD-10-CM. The neoplasm is malignant, and it is in the ascending colon. The ICD-10-CM index for “Neoplasm, by site, colon, ascending” leads to C18.2. This code accurately reflects the documented diagnosis. Therefore, the correct coding sequence for this inpatient encounter, reflecting both the diagnosis and the principal procedure, would be C18.2 for the malignant neoplasm of the ascending colon and 0FT00Z0 for the open resection of the ascending colon with creation of an end colostomy. The explanation focuses on the systematic application of ICD-10-CM and ICD-10-PCS coding principles, emphasizing the identification of root operations, body parts, approaches, devices, and qualifiers within the ICD-10-PCS tabular list, and the accurate translation of diagnostic statements into ICD-10-CM codes by navigating the tabular list and index. It highlights the importance of understanding the hierarchical structure of both coding systems and how to correctly sequence codes for accurate reporting in an inpatient setting, as is fundamental to the curriculum at Certified Coding Specialist (CCS) University.

The core of this question lies in understanding the nuanced application of ICD-10-CM guidelines for sequencing principal and secondary diagnoses, particularly when a patient presents with multiple conditions that influence each other or require specific coding conventions. The scenario describes a patient admitted for management of diabetic ketoacidosis (DKA) secondary to uncontrolled Type 1 diabetes mellitus. The DKA is the immediate reason for admission and the condition that required the most resources and management. According to ICD-10-CM Official Guidelines for Coding and Reporting, Section I.C.10.a.1, the principal diagnosis is defined as “the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” In this case, while Type 1 diabetes is the underlying chronic condition, the DKA is the acute complication that necessitated the inpatient admission. Therefore, DKA should be sequenced first. Furthermore, the guidelines for coding diabetes mellitus with ketoacidosis, found in Section I.C.10.a.2, state that when a patient is admitted with ketoacidosis, the ketoacidosis is coded first, followed by the type of diabetes. This reinforces the sequencing of DKA as the principal diagnosis. The Type 1 diabetes mellitus is a crucial secondary diagnosis that provides context for the DKA. The guidelines also emphasize that if a patient is admitted for management of a diabetic ketoacidosis, the DKA is the principal diagnosis. The presence of hypertension, while a co-morbidity, is not the primary reason for admission or directly influencing the management of the DKA in a way that would alter the principal diagnosis sequencing. Therefore, hypertension would be sequenced after the primary and secondary diabetes-related diagnoses. The correct coding sequence would reflect the acute, primary reason for admission and then the underlying chronic condition, followed by other co-morbidities.

The scenario describes a patient undergoing a complex surgical procedure involving the removal of a malignant neoplasm from the sigmoid colon, followed by a resection and anastomosis. The key to accurately coding this encounter in ICD-10-CM lies in understanding the hierarchical nature of neoplasm coding and the specificity required for malignant tumors. For malignant neoplasms, the primary coding guideline is to assign a code from category C18, Malignant neoplasm of colon, which is further subdivided based on the specific anatomical location within the colon. The documentation explicitly states “sigmoid colon,” which directly corresponds to the subcategory C18.7, Malignant neoplasm of sigmoid colon. The subsequent procedure, a resection and anastomosis, is a surgical intervention. While ICD-10-PCS would be used for the procedure coding, the question focuses on the diagnosis coding in ICD-10-CM. The presence of a malignant neoplasm dictates the primary diagnosis code. The documentation does not indicate any secondary diagnoses that would take precedence or require additional coding beyond the malignant neoplasm of the sigmoid colon. Therefore, the most accurate and specific ICD-10-CM code reflecting the documented condition is C18.7.

The scenario describes a patient undergoing a complex surgical procedure involving the removal of a malignant neoplasm from the sigmoid colon, with a concurrent creation of a colostomy and a subsequent reversal of that colostomy. For ICD-10-CM coding, the primary diagnosis is the malignant neoplasm of the sigmoid colon. The neoplasm’s specific location within the sigmoid colon is crucial for accurate coding. Assuming the documentation specifies the neoplasm is in the sigmoid colon, the appropriate ICD-10-CM code would fall under the C18.7 category. The surgical procedures require ICD-10-PCS coding. The initial procedure involves the resection of the malignant neoplasm of the colon, which is a “Resection” root operation. The site is the colon, and the specific body part is the sigmoid colon. The approach is likely “Open” or “Percutaneous Endoscopic,” depending on the documentation. For the purpose of this question, let’s assume an open approach. The device used would be “No Device.” The qualifier would be “None.” Therefore, a code like 0DTC0ZZ (Resection of Sigmoid Colon, Open Approach) would be representative. The creation of the colostomy is a “Supplement” root operation, specifically “Other Biological” or “Other Mechanical” depending on the stoma creation method, with the body part being the colon and the orifice being the colostomy. A code like 0D1N0ZZ (Supplement of Colon, Open Approach, with no device) would be a simplified representation for stoma creation. The reversal of the colostomy is a “Reversal” root operation, with the body part being the colon and the orifice being the colostomy. A code like 0D1N4ZZ (Reversal of Colostomy, Open Approach) would be appropriate. However, the question asks about the *most appropriate ICD-10-PCS root operation* for the *primary surgical intervention* of removing the tumor. This is the resection of the malignant neoplasm. The root operation “Resection” accurately describes the cutting out of the diseased part of the colon. Other root operations like “Excision” are for cutting out all or part of a body part, but “Resection” is specifically used for cutting out a portion of a body part without replacement. Given the context of removing a tumor and a segment of the colon, “Resection” is the most fitting root operation. The subsequent colostomy creation and reversal are separate procedures. Therefore, the core surgical act of tumor removal is best described by “Resection.”

The scenario describes a patient undergoing a complex surgical procedure involving the creation of a new opening into the small intestine, specifically the ileum, for the purpose of diverting fecal matter. This procedure is a form of ostomy. In ICD-10-PCS, the root operation for creating a new opening into a body part is “Orifice.” The body part involved is the ileum, which is part of the small intestine. The procedure is performed to divert fecal matter, indicating a bypass or diversionary function. The system used for coding such procedures is ICD-10-PCS. The relevant root operation for creating a new opening is “Orifice.” The body system is the digestive system. The body part is the ileum. The approach is typically percutaneous or open, depending on the specifics not detailed here, but for the purpose of identifying the core coding principle, the creation of the opening is key. The objective of the procedure is to divert fecal matter, which is a form of diversion. Therefore, the correct ICD-10-PCS root operation is “Orifice.” The question asks for the root operation that best describes the creation of a new opening into the ileum for diversion. This aligns with the definition of creating a new anatomical orifice.

The scenario describes a patient undergoing a complex surgical procedure involving the removal of a malignant neoplasm from the sigmoid colon, with a concurrent creation of a colostomy and subsequent reversal. For ICD-10-CM coding, the primary diagnosis is the malignant neoplasm of the sigmoid colon. The neoplasm’s behavior (malignant) and location (sigmoid colon) are key. The secondary procedure, the creation of a colostomy, is a consequence of the primary treatment and would be coded as a complication or secondary diagnosis if it directly impacted the patient’s condition or required separate management. However, the question focuses on the *initial* coding of the primary diagnosis. The reversal of the colostomy is a separate procedure that would be coded with its own ICD-10-CM and ICD-10-PCS codes, but it does not alter the primary diagnosis code for the original malignancy. The most specific ICD-10-CM code for malignant neoplasm of the sigmoid colon is C18.7. This code accurately reflects the anatomical site and the pathological nature of the condition as documented. The explanation of why this code is correct involves understanding the hierarchical structure of ICD-10-CM, the importance of specificity in neoplasm coding (distinguishing between primary, secondary, and in situ), and the guidelines for coding conditions that are treated during a single encounter. The presence of a colostomy, while a significant clinical event, is a consequence of the surgical management of the neoplasm and not the primary diagnosis itself. Therefore, the focus remains on accurately identifying the malignancy.

The scenario describes a patient undergoing a complex surgical procedure involving the removal of a malignant neoplasm from the sigmoid colon, necessitating a partial colectomy and the creation of a colostomy. The operative report details the excision of the tumor, the resection of the affected segment of the colon, and the subsequent formation of an end colostomy. In ICD-10-PCS, the root operation for cutting out tissue is “Excision.” The body part is “Colon, Sigmoid.” The approach is “Open” as it involves a surgical incision. The device is “None” as no device is implanted. The qualifier is “None” as there are no further specifications needed for this particular excision. Therefore, the PCS code for the partial colectomy with colostomy creation would involve a root operation of “Bypass” for the colostomy creation, as it reroutes the intestinal contents to an external stoma. The body part for the bypass would be “Colon, Sigmoid” and the body part for the bypass destination would be “Skin, External.” The approach is “Open.” The device is “None.” The qualifier is “None.” Considering the primary procedure is the resection of the malignant neoplasm, which is a partial colectomy, the ICD-10-PCS coding requires identifying the root operation, body part, approach, device, and qualifier. The neoplasm is malignant, and it is excised from the sigmoid colon. The root operation for cutting out solid matter from a body part is “Excision.” The body part is “Colon, Sigmoid.” The approach is “Open” as it involves a surgical incision. No device is used in this excision, so it is coded as “None.” There is no specific qualifier needed for this excision. However, the creation of a colostomy is a separate procedure that reroutes intestinal contents to an external opening. The root operation for diverting a body system’s output to a new external opening is “Bypass.” The body part from which the bypass originates is the “Colon, Sigmoid.” The body part to which the bypass is directed is “Skin, External.” The approach is “Open.” No device is used in the creation of the stoma itself, so it is coded as “None.” There is no qualifier needed for this bypass. Therefore, the correct ICD-10-PCS code for the excision of the malignant neoplasm of the sigmoid colon with partial colectomy is **0DUB0ZZ**. The correct ICD-10-PCS code for the creation of the colostomy is **0D600Z0**. The question asks for the coding of the *excision of the malignant neoplasm*, which is the partial colectomy. The creation of the colostomy is a consequence of the colectomy, but the primary procedure being coded for the neoplasm removal is the excision. The ICD-10-PCS code for the excision of the sigmoid colon is 0DUB0ZZ.

The scenario describes a patient undergoing a laparoscopic cholecystectomy with intraoperative cholangiogram. The primary procedure is the removal of the gallbladder, which in ICD-10-PCS is coded under the Medical and Surgical section, Body System “Biliary Tract,” Root Operation “Excision.” The gallbladder is a body part. Therefore, the root operation is Excision. The approach is laparoscopic, which is coded as “Percutaneous Endoscopic.” The device is “No Device.” The qualifier is “None.” This leads to the code 0FT44ZZ. The intraoperative cholangiogram is a diagnostic imaging procedure performed during the cholecystectomy. In ICD-10-PCS, diagnostic imaging is found in the Imaging section. The body system is “Biliary Tract.” The root operation is “Introduction” for contrast media into the bile ducts. The approach is “Percutaneous Endoscopic.” The device is “Contrast Media.” The qualifier is “None.” This leads to the code 3E033VZ. When multiple procedures are performed during the same operative session, the principal procedure is the one performed for definitive treatment of the condition, or the one that best explains the overall service. In this case, the cholecystectomy is the definitive treatment for cholelithiasis. The cholangiogram is an ancillary diagnostic procedure performed in conjunction with the cholecystectomy. Therefore, the cholecystectomy is coded as the principal procedure. The cholangiogram is coded as a secondary procedure. The correct ICD-10-PCS code for the laparoscopic cholecystectomy is 0FT44ZZ. The correct ICD-10-PCS code for the intraoperative cholangiogram is 3E033VZ. The question asks for the correct coding of both procedures. The combination of the principal procedure (cholecystectomy) and the secondary procedure (cholangiogram) accurately reflects the patient’s encounter. The rationale for selecting the cholecystectomy as the principal procedure is based on its role as the definitive treatment for the diagnosed condition. The cholangiogram, while important, serves a diagnostic purpose during the primary surgical intervention. This aligns with the principles of ICD-10-PCS coding, which prioritizes the most significant procedure when multiple are performed.

The scenario describes a patient undergoing a complex surgical procedure involving the creation of a new opening into the small intestine and the subsequent diversion of intestinal contents to the exterior. In ICD-10-PCS, the root operation “Ostomy” is defined as creating an external opening. The body part is the small intestine, specifically the ileum. The approach is percutaneous, meaning through the skin. The device is a continent ileostomy, which is a type of internal reservoir that allows for controlled emptying. Therefore, the correct root operation is “Ostomy.” The body system is the digestive system. The correct ICD-10-PCS code for creating a continent ileostomy via a percutaneous approach into the ileum, with no device, would be 0DTJ4ZZ. However, the question implies the creation of a stoma with a specific type of internal reservoir, which aligns with the concept of an ostomy. The core of the coding lies in identifying the correct root operation for creating an external opening for diversion. The term “continent” refers to the control mechanism of the stoma, not a separate root operation. The percutaneous approach is a method of accessing the body part. The absence of a specific device code in the options necessitates focusing on the primary procedure. The creation of an external opening for diversion is the defining characteristic.

The scenario describes a patient admitted for an exacerbation of chronic obstructive pulmonary disease (COPD) with an associated acute exacerbation of congestive heart failure (CHF). The physician’s documentation notes “acute exacerbation of COPD” and “acute decompensated CHF.” The primary diagnosis for inpatient coding purposes is the condition chiefly responsible for occasioning the admission. In this case, the COPD exacerbation is explicitly stated as the reason for admission. While CHF is present and treated, it is documented as an exacerbation that occurred concurrently or as a consequence of the primary condition, but not as the principal driver for the admission itself. Therefore, the principal diagnosis should be the COPD exacerbation. The ICD-10-CM coding guidelines, specifically Section I.C.10.a.1.a, state that the principal diagnosis is defined as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” The documentation clearly supports COPD exacerbation as the primary reason. The presence of CHF, while significant, is secondary to the COPD exacerbation in terms of the admission’s primary focus.

The scenario describes a patient undergoing a complex surgical procedure involving the removal of a malignant neoplasm from the ascending colon, necessitating a partial colectomy and creation of an ileocolic anastomosis. The documentation also indicates the use of a laparoscopic approach with conversion to an open procedure due to adhesions. Furthermore, a sentinel lymph node biopsy was performed. To determine the principal diagnosis, we must identify the condition that occasioned the admission. The presence of a malignant neoplasm of the ascending colon is the primary reason for the patient’s hospitalization and the subsequent surgical intervention. Therefore, the appropriate ICD-10-CM code for malignant neoplasm of the ascending colon is the principal diagnosis. For the procedure, ICD-10-PCS coding requires identifying the root operation, body part, approach, device, and qualifier. The removal of the ascending colon segment is a resection. The anatomical site is the colon, specifically the ascending colon. The approach involves both laparoscopic and open methods, with the open approach being the ultimate method of completion. A device is not implanted. The qualifier might specify the type of colectomy. The sentinel lymph node biopsy is a separate procedure. Considering the complexity and the need to select the most accurate representation of the patient’s condition and the services rendered, the principal diagnosis should reflect the malignancy. The question asks for the most appropriate principal diagnosis code. The correct approach involves identifying the primary reason for the encounter, which is the malignant neoplasm. The ICD-10-CM Official Guidelines for Coding and Reporting clearly state that the principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital. In this case, the malignant neoplasm of the ascending colon is that condition. The correct ICD-10-CM code for malignant neoplasm of the ascending colon is C18.2. This code accurately reflects the anatomical location and the nature of the disease process that led to the patient’s admission and subsequent surgical management. The other options represent conditions that might be associated or complications, but not the primary driver of the admission.

The scenario describes a patient undergoing a complex surgical procedure involving the removal of a malignant neoplasm from the sigmoid colon, followed by a partial colectomy and creation of a primary anastomosis. The operative report details the extensive dissection required, including the mobilization of the splenic flexure and the ligation of the inferior mesenteric artery. The neoplasm itself is described as a moderately differentiated adenocarcinoma. To accurately code this encounter using ICD-10-CM and ICD-10-PCS, a systematic approach is necessary. First, the principal diagnosis must reflect the condition that occasioned the admission. In this case, it is the malignant neoplasm of the sigmoid colon. The ICD-10-CM code for a malignant neoplasm of the sigmoid colon is C18.7. Next, the principal procedure performed needs to be identified. The core procedure is the resection of the colon, specifically a partial colectomy. The operative report indicates the removal of a segment of the colon containing the neoplasm. The ICD-10-PCS coding system requires identification of the body part, root operation, approach, device, and qualifier. For the partial colectomy, the body part is the colon. The root operation is “Resection,” as a portion of the organ is removed. The approach is “Open,” as indicated by the surgical incision. No device is left in place, and there is no specific qualifier needed for a standard partial colectomy. Therefore, the ICD-10-PCS code for the partial colectomy of the sigmoid colon is 0DTT0ZZ. The operative report also mentions the creation of a primary anastomosis. This is an integral part of the colectomy and is typically included within the scope of the resection code when a primary anastomosis is performed. However, if considered a separate, distinct procedure, it would be coded as “Anastomosis” with the root operation “Bypass” or “Other” depending on the specific technique and intent, but in the context of a primary closure following resection, it’s usually encompassed. Given the options, the most accurate representation of the primary procedure is the resection. The question asks for the most appropriate ICD-10-CM code for the principal diagnosis. Based on the documentation of a malignant neoplasm of the sigmoid colon, the correct ICD-10-CM code is C18.7.

The scenario describes a patient undergoing a complex surgical procedure involving the creation of a new opening into the small intestine and the performance of a partial excision of the small intestine. In ICD-10-PCS, the root operation for creating a new opening into a body part is “Orifice.” The root operation for cutting out or off, without replacement, a portion of a body part is “Excision.” The body part for the new opening is the small intestine, which is coded as “0DT” in ICD-10-PCS (Body Part: Small Intestine, Approach: Open). The procedure involves creating an orifice, so the first character of the PCS code will be “0” (Medical and Surgical). The second character represents the body system, which is the gastrointestinal system, coded as “D” (Gastrointestinal System). The third character is the root operation for creating a new opening, which is “T” (Orifice). The fourth character specifies the body part, the small intestine, coded as “0” (Small Intestine). The fifth character indicates the approach, which is open, coded as “0” (Open). Therefore, the PCS code for creating the new opening into the small intestine is 0DT00Z0. The second part of the procedure involves the partial excision of the small intestine. The root operation for this is “Excision.” The body part is the small intestine, coded as “0DT” (Body Part: Small Intestine, Approach: Open). The root operation is “Excision,” coded as “B” (Excision). The body part is the small intestine, coded as “0” (Small Intestine). The approach is open, coded as “0” (Open). The device is none, coded as “Z” (No Device). The qualifier is none, coded as “Z” (No Qualifier). Therefore, the PCS code for the partial excision of the small intestine is 0DB00Z0. When multiple procedures are performed, the principal procedure is the one that best meets the definition of principal procedure, which is generally the one performed for definitive treatment of the condition. In this case, both procedures are significant. However, the creation of the stoma (orifice) is often considered the definitive procedure for diversion or access, and the excision is a secondary procedure. Therefore, the creation of the orifice is likely the principal procedure. The question asks for the correct ICD-10-PCS code for the principal procedure. Based on the analysis, the creation of the new opening into the small intestine is the principal procedure. The ICD-10-PCS code for creating a new opening into the small intestine, with an open approach, is 0DT00Z0.

The scenario describes a patient undergoing a complex surgical procedure for a malignant neoplasm of the sigmoid colon. The operative report details a sigmoid colectomy with a partial resection of the adjacent mesentery and a primary anastomosis. The pathology report confirms adenocarcinoma of the sigmoid colon, with invasion into the serosa and involvement of three of the fifteen examined lymph nodes. The staging information indicates T3N1aM0. In ICD-10-CM, the primary diagnosis for a malignant neoplasm of the sigmoid colon is C18.7. The staging information (T3N1aM0) is crucial for understanding the extent of the disease but does not directly alter the primary ICD-10-CM code for the malignancy itself. The operative procedure, a sigmoid colectomy with mesentery resection and anastomosis, is a treatment for this condition. When coding for a malignant neoplasm, the primary focus is on identifying the specific site of the malignancy. The sigmoid colon is a distinct anatomical location within the large intestine. ICD-10-CM provides specific codes for neoplasms based on their anatomical site. Code C18.7 specifically designates “Malignant neoplasm of sigmoid colon.” The additional details regarding serosal invasion and lymph node involvement, while critical for staging and prognosis (e.g., TNM staging), do not necessitate a change in the primary ICD-10-CM code for the malignant neoplasm of the sigmoid colon. The ICD-10-CM coding system prioritizes the site of the malignancy as the primary diagnostic code. Subsequent codes or additional information might be used to further specify the extent or characteristics of the disease, but for the primary diagnosis of the malignant neoplasm of the sigmoid colon, C18.7 is the correct and most specific code. The question asks for the principal diagnosis code for the malignant neoplasm of the sigmoid colon.

The scenario describes a patient undergoing a complex surgical procedure involving the creation of a new opening into the small intestine, specifically the ileum, and connecting it to the skin surface. This procedure is known as an ileostomy. In ICD-10-PCS, the root operation for creating a new opening into a body part is “STRUCTION.” The body system involved is the digestive system. The specific body part is the ileum, which is a segment of the small intestine. Therefore, the root operation isSTRUCTION, the body part is Ileum, and the approach is percutaneous endoscopic. The ICD-10-PCS code for this procedure would be constructed by identifying these components. The root operation isSTRUCTION, which signifies creating a new opening. The body part is the Ileum (part of the small intestine). The approach is percutaneous endoscopic, indicating the method used to access the body part. Combining these elements according to ICD-10-PCS conventions leads to the correct code.

The scenario describes a patient undergoing a laparoscopic cholecystectomy with intraoperative cholangiography. The primary procedure is the removal of the gallbladder, which falls under the root operation “Excision” in ICD-10-PCS. The gallbladder is a body part. Therefore, the body part value for the gallbladder is appropriate. The approach for a laparoscopic procedure is “Percutaneous Endoscopic,” as it involves entry through small punctures using a scope. The device used is typically a “No Device” as no specific device is left in place to aid healing or function. The qualifier for this procedure is “None” as there is no further specification needed. The intraoperative cholangiography is a diagnostic imaging procedure performed during the cholecystectomy. In ICD-10-PCS, imaging of a body part is classified under the root operation “Imaging.” The body part being imaged is the biliary tract. The approach for this is also “Percutaneous Endoscopic” due to the laparoscopic nature. The device used is “Contrast Media” as it is injected to visualize the ducts. The qualifier is “None” as no specific anatomical region of the biliary tract is being further specified beyond the general imaging. Therefore, the correct ICD-10-PCS codes would reflect these root operations, body parts, approaches, devices, and qualifiers. The explanation focuses on the systematic application of ICD-10-PCS guidelines to dissect the procedure into its component parts, aligning with the rigorous analytical skills expected of Certified Coding Specialist (CCS) University students. This process emphasizes understanding the logic behind code assignment rather than rote memorization, a core tenet of the university’s academic philosophy. The detailed breakdown ensures that candidates grasp the nuances of root operations, body part selection, and approach determination, crucial for accurate coding in complex surgical scenarios.

The scenario describes a patient undergoing a complex surgical procedure involving the removal of a malignant neoplasm from the sigmoid colon, followed by a primary anastomosis. The key elements for accurate ICD-10-CM coding are the principal diagnosis and the secondary diagnoses, along with relevant procedures. The principal diagnosis is the condition chiefly responsible for the admission. In this case, it is the malignant neoplasm of the sigmoid colon. The ICD-10-CM code for malignant neoplasm of the sigmoid colon is C18.7. The patient also has a history of hypertension, which is a co-morbidity and should be coded as a secondary diagnosis. The ICD-10-CM code for essential hypertension is I10. The procedure involves the excision of the sigmoid colon and a primary anastomosis. In ICD-10-PCS, the root operation for removing part of an organ is “Resection.” The body part is “Colon, Sigmoid.” The approach is “Open” (assuming a traditional surgical incision, as no other approach is specified). The device is “None” as no device is left in place. Therefore, the ICD-10-PCS code for the resection of the sigmoid colon is 0DTJ0ZZ. The anastomosis, which is the joining of two lumens, is a separate root operation. The root operation for joining is “Anastomosis.” The body part for the anastomosis would be the colon itself, or more specifically, the sigmoid colon and the distal part of the colon. The approach is again “Open.” The device is “None.” The Qualifier would specify the type of anastomosis, but for a primary anastomosis, it’s often implied or not explicitly coded with a qualifier if it’s a standard procedure. A common PCS code for anastomosis of the colon is 0DQC0ZZ. However, the question asks for the *most appropriate* ICD-10-CM code for the *diagnosis*. Therefore, focusing on the diagnostic coding, C18.7 for the malignant neoplasm of the sigmoid colon is the principal diagnosis. The hypertension (I10) is a secondary diagnosis. The question specifically asks for the ICD-10-CM code for the *principal diagnosis*.

The scenario presented involves a patient undergoing a complex surgical procedure. The core of the question lies in accurately identifying the principal diagnosis and the most appropriate ICD-10-CM code for the patient’s primary condition, considering the nuances of coding guidelines for neoplasms. The patient is diagnosed with a malignant neoplasm of the ascending colon, which has metastasized to the liver. The operative report details a hemicolectomy of the ascending colon and a partial hepatectomy for the liver metastasis. According to ICD-10-CM Official Guidelines for Coding and Reporting, when a patient has a primary malignancy and a secondary malignancy, and both are treated during the same encounter, the primary malignancy is sequenced first. In this case, the ascending colon neoplasm is the primary site. The guidelines also state that if a secondary site is treated, it should be coded as a secondary malignant neoplasm. Therefore, the principal diagnosis should reflect the malignant neoplasm of the ascending colon. The ICD-10-CM code for malignant neoplasm of the ascending colon is C18.2. The metastasis to the liver is a secondary site. The ICD-10-CM code for secondary malignant neoplasm of the liver is C78.7. The question asks for the principal diagnosis code. The principal diagnosis is defined as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. In this case, the ascending colon cancer is the primary reason for the surgical intervention, even though the liver metastasis is also addressed. The coding convention for neoplasms dictates that the primary site is coded first. Thus, the correct ICD-10-CM code for the principal diagnosis is C18.2. This reflects the malignant neoplasm of the ascending colon, which is the primary focus of the patient’s admission and treatment. Understanding the hierarchy of coding for primary and secondary malignancies, as well as the definition of principal diagnosis, is crucial for accurate coding in complex oncology cases, a key competency emphasized at Certified Coding Specialist (CCS) University. The ability to discern the primary condition from secondary manifestations is a fundamental skill tested in advanced coding curricula.

The scenario describes a patient undergoing a complex surgical procedure involving the removal of a malignant neoplasm from the ascending colon, followed by a partial colectomy and anastomosis. The documentation specifies the use of an open approach. In ICD-10-PCS, the root operation for cutting out all of the diseased part of an organ is “Resection.” The body part is the “Ascending Colon.” The approach is “Open.” The device is “No Device” as no prosthesis or graft is mentioned. The qualifier is also “No Qualifier” as there is no further specification needed to uniquely identify the procedure. Therefore, the PCS code for this procedure is 0DTJ0ZZ. This question assesses the understanding of ICD-10-PCS coding principles, specifically the selection of root operations, body parts, approaches, and qualifiers for complex surgical procedures. A Certified Coding Specialist at Certified Coding Specialist University must be adept at dissecting operative reports to identify the core components of a procedure and translate them into the precise PCS code. The ability to differentiate between similar root operations, such as resection versus excision, based on the extent of tissue removed, is crucial. Furthermore, understanding the nuances of the approach (open vs. percutaneous vs. endoscopic) and the application of qualifiers to distinguish between similar procedures is paramount for accurate coding and subsequent reimbursement and data analysis, which are core competencies emphasized in Certified Coding Specialist University’s curriculum. This question probes the candidate’s ability to apply these detailed coding rules to a realistic clinical scenario, reflecting the practical challenges faced by coding professionals in healthcare settings.

The scenario describes a patient undergoing a complex surgical procedure involving the removal of a malignant neoplasm from the sigmoid colon, followed by a partial colectomy and creation of a primary anastomosis. The key to accurate ICD-10-CM coding lies in identifying the principal diagnosis and all relevant secondary diagnoses, as well as the principal procedure and any significant secondary procedures. The principal diagnosis is the condition chiefly responsible for occasioning the admission of the patient to the hospital. In this case, the malignant neoplasm of the sigmoid colon is the primary reason for the surgical intervention. Therefore, the appropriate ICD-10-CM code for this would be C18.7 (Malignant neoplasm of sigmoid colon). The surgical procedure involves the removal of the tumor and a portion of the colon, followed by rejoining the remaining segments. This is a partial colectomy. The ICD-10-PCS code for this procedure would reflect the root operation of resection, the body part as sigmoid colon, the approach as open, and the device as none. The specific PCS code for an open partial colectomy of the sigmoid colon is 0DTC0ZZ. The explanation must focus on the rationale for selecting these codes based on the provided clinical information and the ICD-10-CM and ICD-10-PCS coding guidelines. It should emphasize the hierarchical nature of coding, starting with the principal diagnosis and then identifying all relevant procedures. The explanation should also touch upon the importance of understanding anatomical locations and surgical terminology to accurately assign codes. For instance, differentiating between a partial and total colectomy, or understanding the meaning of “anastomosis,” is crucial for correct procedure coding. The presence of a malignant neoplasm dictates the primary diagnostic code, and the surgical intervention to remove it and restore continuity of the bowel requires a specific procedural code that captures the extent of the resection and the method of reconstruction. The explanation should also highlight how these codes are used for various purposes, such as reimbursement, statistical analysis, and quality monitoring, underscoring the critical role of the Certified Coding Specialist in ensuring data integrity within the healthcare system, particularly within the context of Certified Coding Specialist University’s commitment to rigorous academic standards and practical application.

The scenario describes a patient undergoing a laparoscopic cholecystectomy with intraoperative cholangiogram. The primary procedure is the removal of the gallbladder, which in ICD-10-PCS is coded under the Medical and Surgical section, Body System ‘Gallbladder’, Root Operation ‘Excision’. The approach is ‘Percutaneous Endoscopic’ as it’s laparoscopic. The device is ‘No Device’ as no device is left in place. The qualifier is ‘None’. This yields the code 0FT44ZZ. The intraoperative cholangiogram is a diagnostic procedure performed during the cholecystectomy. In ICD-10-PCS, diagnostic imaging of the biliary tract falls under the Imaging section, Body System ‘Biliary Tract’, Root Operation ‘Plain Radiography’. The approach is ‘Percutaneous Endoscopic’. The device is ‘Contrast Material’ as contrast is used for the imaging. The qualifier is ‘None’. This yields the code 3E033VZ. When multiple procedures are performed during the same operative session, the principal procedure is the one performed for definitive treatment of the condition or for the condition that occasioned the admission. In this case, the cholecystectomy is the definitive treatment for cholelithiasis. The cholangiogram is an ancillary diagnostic procedure performed during the cholecystectomy. Therefore, the cholecystectomy is coded as the principal procedure. The cholangiogram is coded as a secondary procedure. The question asks for the correct ICD-10-PCS coding for the scenario. The correct coding requires identifying the principal procedure and any secondary procedures, applying the correct root operations, body systems, approaches, devices, and qualifiers for each. The explanation above details the derivation of the codes for both the cholecystectomy and the cholangiogram, and establishes the cholecystectomy as the principal procedure. The correct ICD-10-PCS codes are: Principal Procedure: 0FT44ZZ (Excision of Gallbladder, Percutaneous Endoscopic Approach) Secondary Procedure: 3E033VZ (Plain Radiography of Biliary Tract, Percutaneous Endoscopic Approach, with Contrast Material) Therefore, the correct option reflects these two codes in the appropriate order.

The scenario describes a patient undergoing a complex surgical procedure involving the removal of a malignant neoplasm from the ascending colon, with a concurrent creation of a colostomy. The primary procedure is a partial colectomy, specifically a right hemicolectomy, for a malignant neoplasm. The creation of a colostomy is a separate, distinct procedure. In ICD-10-PCS, the root operation for removing part of a body organ is “Resection.” The body part is the “Ascending Colon.” Since it’s a malignant neoplasm, the objective is to “Ex” (Excision) or “Re” (Resection) the tumor. Given the removal of a portion of the colon, “Resection” is the appropriate root operation. The approach is “Open” as it’s a surgical procedure. The device is “None” as no device is left in place. The qualifier is “None” as there is no further specification needed for the resection of the ascending colon. Therefore, the code for the right hemicolectomy would be 0DTC0ZZ. The creation of a colostomy is a separate procedure. The root operation for creating an opening to the outside is “Ostomy.” The body part is the “Colon.” The objective is to create an opening, so the objective is “B” (Bypass) to create a diversion. However, for ostomy creation, the objective is “D” (Diversion) to create a new opening. The approach is “Open.” The device is “Ostomy Device” (4). The qualifier is “Colostomy” (W). Therefore, the code for the colostomy creation would be 0D504W1. The question asks for the correct ICD-10-PCS code for the creation of a colostomy following a right hemicolectomy for a malignant neoplasm of the ascending colon. While the hemicolectomy is performed, the question specifically targets the colostomy creation. The ICD-10-PCS root operation for creating an opening to the outside of the body is “Ostomy.” The body part is the “Colon.” The objective is to create a diversion, which is coded as “D.” The approach is “Open” (0). A device is placed, specifically an ostomy device (4). The qualifier for a colostomy is “Colostomy” (W). Thus, the ICD-10-PCS code for the creation of a colostomy is 0D504W1.

The scenario describes a patient undergoing a complex surgical procedure involving the removal of a malignant neoplasm from the sigmoid colon, followed by a partial colectomy and creation of a primary anastomosis. The key to accurate ICD-10-CM coding lies in identifying the principal diagnosis and all relevant secondary diagnoses, as well as the principal procedure and any significant secondary procedures. The principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital. In this case, it is the malignant neoplasm of the sigmoid colon. The ICD-10-CM code for malignant neoplasm of the sigmoid colon is C18.7. The patient also has a history of hypertension, which is a co-morbidity that can affect patient care and management. Hypertension is coded as I10. The patient also has a history of type 2 diabetes mellitus with hyperglycemia, which is coded as E11.65. The principal procedure is the partial colectomy with anastomosis. The ICD-10-PCS code for a partial colectomy of the colon, with anastomosis, would involve identifying the body part (colon), root operation (resection for removal of the neoplasm, and construction for the anastomosis), body system (digestive system), approach (open or percutaneous endoscopic), and device (none or a specific type of anastomosis device if used). Assuming an open approach and no specific device, a representative code could be 0DUB0ZZ (Resection of Colon, Open Approach) for the colectomy and 0DQC0ZZ (Construction of Anastomosis of Intestine, Open Approach) for the anastomosis, though ICD-10-PCS requires a single code that encompasses the primary objective. A more accurate representation for the combined procedure of resection and anastomosis would be a single root operation like “Resection” with a qualifier for the type of anastomosis, or potentially separate codes if the system dictates. However, for the purpose of this question, focusing on the primary diagnosis and relevant comorbidities is key. The question asks for the most appropriate principal diagnosis code. Based on the information provided, the malignant neoplasm of the sigmoid colon is the condition that necessitated the admission and surgical intervention. Therefore, C18.7 is the correct principal diagnosis code. The other conditions, hypertension and diabetes, are important but are secondary to the primary reason for admission.