Although the patient has both sepsis and acute kidney failure, the documentation does not establish a causal relationship between the two conditions. Coders should not assume severe sepsis unless the provider documents that the organ dysfunction is associated with the sepsis or explicitly diagnoses severe sepsis.

CCS Case Study #3 Answer Key

Recurrent Left Knee Pain Due to Complex Medial Meniscus Tear

Correct ICD-10-CM Code

S83.232A – Complex tear of medial meniscus, current injury, left knee, initial encounter

Correct ICD-10-PCS Code

0SBD4ZZ – Excision of Left Knee Meniscus, Percutaneous Endoscopic Approach

ICD-10-CM Coding Rationale

The patient presented with a confirmed complex tear of the medial meniscus of the left knee after conservative treatment failed.

Because a definitive diagnosis was established, associated symptoms such as knee pain, swelling, and decreased range of motion are not coded separately, as they are integral to the confirmed diagnosis.

Refer to the ICD-10-CM Official Guidelines for Coding and Reporting regarding the assignment of confirmed diagnoses versus associated symptoms.

ICD-10-PCS Coding Rationale

The operative report documents an arthroscopic partial medial meniscectomy of the left knee.

Since only a portion of the medial meniscus was removed, the correct ICD-10-PCS root operation is Excision.

The procedure was performed arthroscopically, which supports the Percutaneous Endoscopic approach.

ICD-10-PCS Breakdown

Section: 0 – Medical and Surgical
Body System: S – Lower Joints
Root Operation: B – Excision
Body Part: D – Left Knee Meniscus
Approach: 4 – Percutaneous Endoscopic
Device: Z – No Device
Qualifier: Z – No Qualifier

Final ICD-10-PCS Code: 0SBD4ZZ

Critical Thinking Answers

1. What is the principal diagnosis?

Complex tear of the medial meniscus, left knee.

2. What body system is involved?

Lower Joints

3. What ICD-10-PCS root operation was performed?

Excision

Rationale: Only a portion of the meniscus was removed during the procedure.

4. What approach was used?

Percutaneous Endoscopic

Rationale: The procedure was performed arthroscopically.

5. What documentation supports the ICD-10-PCS code assignment?

The operative report documents:

Arthroscopic portals were established.
A complex tear of the left medial meniscus was identified.
The torn portion of the meniscus was removed.
The remaining meniscal tissue was stable.
The procedure was completed arthroscopically without placement of a device.

These findings support assignment of ICD-10-PCS code 0SBD4ZZ.

CCS Coding Tip

When assigning ICD-10-PCS codes, focus on the objective of the procedure rather than the procedure name.

A partial meniscectomy is coded to the root operation Excision because only a portion of the body part is removed. If the entire meniscus had been removed, the correct root operation would be Resection.

Always verify the root operation, body part, approach, device, and qualifier using the ICD-10-PCS Tables before assigning the final code.