Question

OPERATION: The patient was identified in the preoperative holding area and taken to the operative suite at which time general anesthesia was induced. He was then placed in the left lateral decubitus position with the right side up, padding pressure points and prepped and draped in standard fashion for placement of baclofen pump. After appropriate time-out to identify the patient, correct location and operation, the operation commenced. A 1% lidocaine with 1:200,000 epinephrine was instilled in previous incision in the low back at approximately the level of L4-L5. Intraoperative fluoroscopy was used to help confirm this level. A Tuohy needle was used to attempt a lumbar puncture. Because of the patient's previous surgery and also the body habitus, it was difficult to attain CSF after three attempts. A second neurosurgeon also tried to access with a longer needle with no success. After multiple attempts at CSF access, it was recommended to abort the procedure and bring the patient back for an open procedure to see if access to the thecal space could be accomplished in that manner. The wound was then copiously irrigated and closed using 3-0 Vicryl interrupted sutures and staples for the skin. The sterile dressing was applied. The patient was extubated in the operating room and taken to post- anesthesia care unit in stable and unchanged condition. Plan was for him to be returning back to the operating room in 1 week.

Questions

1. What is the best way to dissect this operative report in terms of ICD-10-PCS?
2. What is the root operation(s)?
3. How many root operations are in this operative report?
4. What is the approach?
5. What is the device code?
6. What is the qualifier code?
7. What are the ICD-10-PCS code(s) associated with this question?

Answer 1

What is the best way to dissect this operative report in terms of ICD-10-PCS?

ICD-10-PCS code can be dissected well by analyzing the table for section, body system, root operation, body part used, the type of approach, and used device and qualifier.

What is the root operation(s)?

The root operation is J. Because they are inspecting the body part to remove CSF fluids. The lumbar part is visually explored for puncturing. So the root operation J is used.

How many root operations are in this operative report?

Only a single root operation of J (inspection) is assigned even though the surgeon attempted three times.

What is the approach?

The approach is 3. The percutaneous approach is used to Puncturing of the Lumbar site to remove CSF fluid.

What is the device code?

No device code is used. Hence Device code is Z.

What is the qualifier code?

Qualifier code is Z. No qualifier.

What are the ICD-10-PCS code(s) associated with this question?

00JU3ZZ

1. Section - 0 - Medical and surgical

2. Body system - 0 - Central nervous system.

3. Root operation - J - inspection

4. Body part - U - Subindex of the Body system.

5. approach - 3 - percutaneous

6. Device - Z - No Device

7. Qualifier - Z - No Qualifier.