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Code This!

Scenario Week of April 10, 2015:
View Current Scenario

Assign the correct ICD-9-CM and ICD-10-CM diagnosis and PCS procedure codes for the following inpatient coding scenario.

HISTORY AND PHYSICAL: 75-year-old female presented with progressive fatigue, 10-pound weight loss over three months’ time. She denied changes in bowel habits, melena, or blood per rectum. Her only current medication is aspirin prn for low back discomfort. She had not seen a physician for several years except for a respiratory tract infection when she saw me for the first time three weeks ago.

The patient was found to be anemic and underwent colonoscopy with biopsy of a large polypoid lesion at the hepatic flexure, which was found on pathologic examination to be adenocarcinoma.

SOCIAL HISTORY: Non-smoker, negative ETOH

FAMILY HISTORY: Significant for family history of father with heart attack, mother with CHF


PREOPERATIVE DIAGNOSIS: Right colon (hepatic flexure) mass, biopsy proven moderately differentiated adenocarcinoma;
Iron deficiency anemia secondary to chronic gastrointestinal blood loss


OPERATION: Right hemicolectomy

FINDINGS: 4-5cm mass in the right colon hepatic flexure, no metastases noted. The remainder of the exploration was unrevealing.

PROCEDURE: With the patient in the supine position and under satisfactory general anesthesia, the abdomen was prepped and draped in the usual fashion. The abdomen was entered through a midline incision. Exploration was carried out. The right colon was mobilized by incising the lateral peritoneal attachments and rotating the colon medially. The right half of the gastric colonic omentum was clamped, divided, and tied. Distal ileum was immobilized. Just to the right of the mid colonic artery, the mesentery was incised toward the base and then toward the distal ileum.

Blood supply to the right colon distal ileum was clamped, divided, and tied, thus completing division. At approximately 5 cm proximal to the ileocecal valve, the mid transverse colon was cleared and held together with clamps. Small incisions were then made in each. A GIA stapler was inserted and fired along the antimesenteric border. Anastomosis was completed via transverse application of TAs, specimen excised. The anchoring sutures proximally and distally were placed and the mesenteric defect was closed. Anastomosis was widely patent. Irrigation was carried out. Peritoneum was closed with running Vicryl, fascia with running Vicryl, skin with clips. Sterile dressings applied. Blood loss was minimal. All surgical counts were correct. There were no complications.

Code this scenario with ICD-9-CM, ICD-10-CM and PCS codes.


ICD-9-CM Diagnosis Codes
153.0 Malignant neoplasm of hepatic flexure
280.0 Iron deficiency anemia secondary to blood loss (chronic)

ICD-9-CM Procedure Code
45.73 Open and other right hemicolectomy

ICD-10-CM Diagnosis Codes
C18.3 Malignant neoplasm of hepatic flexure
D50. Iron deficiency anemia secondary to blood loss (chronic)

ICD-10-PCS Code
0DTF0ZZ Resection of Right Large Intestine, Open Approach


ICD-9-CM Diagnoses
The patient was admitted with biopsy-proven adenocarcinoma of the hepatic flexure. Refer to the alphabetic index under the terms Adenocarcinoma, intestinal type, specified site – see Neoplasm, by site, malignant. In the neoplasm table, the term colon refers to see also Neoplasm, intestine, large. Intestine, large is further subdivided into colon and hepatic flexure. Because the neoplasm is in the hepatic flexure, select code 153.0 under the Malignant column. Refer to the tabular listing for code 153.0 to confirm this is the correct code assignment.

The patient was also documented as having iron deficiency anemia due to chronic gastrointestinal blood loss. See the alphabetic index entry Anemia, blood loss (chronic) 280.0, or Anemia, iron (Fe) deficiency, due to blood loss (chronic) 280.0. Review of the tabular listing for code 280.0 indicates this is the correct code assignment.

ICD-9-CM Procedure
Resection of the right colon is reported with code 45.73 Right hemicolectomy. An additional code is not reported for the end-to-end anastomosis accomplished with the GIA and TA staplers. This is confirmed by the instructional note under subcategory 45.9 Intestinal anastomosis, which states: “Excludes end-to-end anastomosis – omit code.”

ICD-10-CM Diagnoses
The ICD-10-CM diagnosis codes are indexed similarly to ICD-9-CM. See the neoplasm table entry under Intestine, large, hepatic flexure, under the Malignant column code C18.3. The tabular entry for code C18.3 confirms this is the complete correct code.

The index terms Anemia, blood loss (chronic) D50.0, or Anemia, iron deficiency, secondary to blood loss (chronic) D50.0 both lead to the same code. This code is validated according to the tabular listing.

The procedure performed was a right hemicolectomy. In ICD-10-PCS, the right large intestine (colon) is defined as its own body part. Resection includes all of a body part, or any subdivision of a body part that has its own body part value in ICD-10-PCS, while Excision includes only a portion of a body part. Because the surgeon removed the entire subdivision of the body part with its own body part value (the right half of the large intestine), the correct root operation is Resection. Refer to the ICD-10-PCS Table 0DT, Resection / Gastrointestinal System; fourth character F for large intestine, right; fifth character 0 for open approach; sixth and seventh character values ZZ complete the code.

According to ICD-10-PCS Guideline B3.1b, the anastomosis regardless of technique is not reported separately: “Components of a procedure specified in the root operation definition and explanation are not coded separately. Procedural steps necessary to reach the operative site and close the operative site, including anastomosis of a tubular body part, are also not coded separately.” Therefore, only the resection code is assigned.

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