CMS Finally Gets Root Operation Control Right

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Original story posted on: September 27, 2021

In my view, the latest change to this guideline is the best so far.

The current definition of the root operation Control is “stopping, or attempting to stop, postprocedural or other acute bleeding.”

Since the implementation of ICD-10-PCS on Oct. 1, 2015, this definition and associated guideline have undergone several revisions. Effective with discharges on and after Oct. 1, 2021, guideline B3.7, Control vs. more specific root operations, is being tweaked yet again. Before delving into what’s new, let’s take a walk down memory lane and see how we got here.

The first change came in fiscal year 2017, and significantly altered how we code for hemorrhage control. The original intent of this root operation was to stop or attempt to stop postprocedural bleeding. In 2017, the definition was expanded to include control of either postprocedural or other acute bleeding, and the guideline was updated to reflect this change. The original guideline went on to state that if an attempt to stop the bleeding is initially unsuccessful and any of the definitive root operations of Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection are performed, that definitive root operation is coded instead.

Differences between the versions are highlighted in bold:

FY 2016

FY 2017

B3.7 Control vs. more definitive root operations

The root operation Control is defined as “stopping, or attempting to stop, postprocedural bleeding.” If an attempt to stop postprocedural bleeding is initially unsuccessful, and to stop the bleeding requires performing any of the definitive root operations Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then that root operation is coded instead of Control.

Example: Resection of spleen to stop postprocedural bleeding is coded to Resection instead of Control.

B3.7 Control vs. more definitive root operations

The root operation Control is defined as “stopping, or attempting to stop, postprocedural or other acute bleeding.” If an attempt to stop postprocedural or other acute bleeding is initially unsuccessful, and to stop the bleeding requires performing any of the definitive root operations Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then that root operation is coded instead of Control.

Example: Resection of spleen to stop bleeding is coded to Resection instead of Control.

In 2018, what looked like a minor change to the guidelines made another big change to how we code. The addition of the words “such as” indicated this list was not all inclusive, and there could be other root operations used to control bleeding outside of those listed in the guideline. For example, I remember seeing discussion boards around this time discussing the appropriate root operation to use for embolization of an arterial bleed for treatment of a bleeding stomach ulcer. Embolization in this situation is coded as Occlusion, but it’s not on that list. 

FY 2017

FY 2018

B3.7 Control vs. more definitive root operations

The root operation Control is defined as “stopping, or attempting to stop, postprocedural or other acute bleeding.” If an attempt to stop postprocedural or other acute bleeding is initially unsuccessful, and to stop the bleeding requires performing any of the definitive root operations Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then that root operation is coded instead of Control.

Example: Resection of spleen to stop bleeding is coded to Resection instead of Control.

B3.7 Control vs. more definitive root operations

The root operation Control is defined as “stopping, or attempting to stop, postprocedural or other acute bleeding.” If an attempt to stop postprocedural or other acute bleeding is initially unsuccessful, and to stop the bleeding requires performing a more definitive root operation, such as Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then the more definitive root operation is coded instead of Control.

Example: Resection of spleen to stop bleeding is coded to Resection instead of Control.

The 2018 guideline change also left another questionable word in the definition: “initially.” The use of this root operation was supposed to be a secondary attempt to achieve hemostasis, but that was also causing coder confusion. What constitutes an initial unsuccessful attempt? So, in the following year, the Centers for Medicare & Medicaid Services (CMS) removed that word.

FY 2019

B3.7 Control vs. more definitive root operations

The root operation Control is defined as “stopping, or attempting to stop, postprocedural or other acute bleeding.” If an attempt to stop postprocedural or other acute bleeding is initially unsuccessful, and to stop the bleeding requires performing a more definitive root operation, such as Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then the more definitive root operation is coded instead of Control.

Example: Resection of spleen to stop bleeding is coded to Resection instead of Control.

In my view, the latest change to this guideline is the best so far. First off, the guideline title is being changed from “Control vs. more definitive root operations” to “Control vs. more specific root operations.” Second, it specifies that this root operation is to be used when the procedure performed to control bleeding is above and beyond normal hemostasis measures considered integral to the primary surgical procedure. Third, it adds language clarifying the use of a more specific root operation rather than Control. And finally, three distinct examples are given to show when the root operation Control is used, when a more specific root operation is used, and when no additional code is necessary.

FY 2022

B3.7 Control vs. more specific root operations

The root operation Control is defined as “stopping, or attempting to stop, postprocedural or other acute bleeding.” Control is the root operation coded when the procedure performed to achieve hemostasis, beyond what would be considered integral to a procedure, utilizes techniques (e.g. cautery, application of substances or pressure, suturing or ligation or clipping of bleeding points at the site) that are not described by a more specific root operation definition, such as Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection. If a more specific root operation definition applies to the procedure performed, then the more specific root operation is coded instead of Control.

Example: Silver nitrate cautery to treat acute nasal bleeding is coded to the root operation Control.

Example: Liquid embolization of the right internal iliac artery to treat acute hematoma by stopping blood flow is coded to the root operation Occlusion.

Example: Suctioning of residual blood to achieve hemostasis during a transbronchial cryobiopsy is considered integral to the cryobiopsy procedure and is not coded separately.

If you’ve been struggling to unpack coding guidance for control of postoperative or acute bleeding, this is your year! It’s frustrating that it sometimes takes several years to get a coding guideline “right,” but I think they’ve finally done it.

Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-Approved ICD-10-CM/PCS Trainer

Kristi is the Director of Coding Quality & Education at Haugen Consulting Group. Kristi has more than 25 years of industry experience. She develops web-based and instructor-led training material and conducts training and audits in ICD-10-CM/PCS and CPT®. Kristi has an extensive background in coding education and consulting and is a national speaker on topics related to ICD-10 and CPT coding, as well as code-based reimbursement.

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