Updated on: September 23, 2013

Medical and Surgical Root Operations of Body Parts: Removing and Examining

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Original story posted on: January 23, 2012

EDITOR’S NOTE: This is the third in a series of articles addressing the definitions and differences between the Medical and Surgical Root Operations.

Let's review what we covered so far. In the Medical and Surgical section (first character 0), there are 31 root operations using standardized terminology with no procedure names, diagnostic information or eponyms. You won't find an appendectomy in ICD-10-PCS, but you will need to know that the cutting out or off, without replacement, of all of a body part is known as a resection. Since an appendectomy the majority of the time involves the total removal of the appendix, resection is the correct root operation in this case. This is the type of translation coders must make to ensure accurate code assignment.

Today we will focus on two groups of root operations. As in the ICD-10-PCS book, we will review definitions, explanations and some examples of each. We also will introduce the applicable coding guidelines. Our first group is the three root operations referring to the taking out or elimination of solid matter, fluids or gases from a body part. These procedures do not focus on the body part itself, but on the material being removed, be it solid, liquid or gas. The character listed after each root operation represents the third character in the PCS codes.

 

Drainage (9) Definition: Taking or letting out fluids and/or gases from a body part
Explanation: The qualifier "diagnostic" is used to identify drainage procedures that are also biopsies
Examples: Thoracentesis incision and drainage, routine Foley catheter placement, laparoscopy with right ovarian cystotomy and drainage

Coding Guideline: Drainage device (B6.2)

A separate procedure to put in a drainage device is coded to the root operation "drainage" with the device value "drainage device."

Extirpation (C) Definition: Taking or cutting out of solid matter from a body part
Explanation: The solid matter may be an abnormal by product of a biological function or foreign body, or it may be embedded in a body part. The solid matter may or may not previously have been broken into pieces.
Examples: Thrombectomy, choledocholithotomy, removal of foreign body (open or closed approach)
Fragmentation (F) Definition: Breaking solid matter in a body part into pieces
Explanation: Physical force (manual or ultra-sonic force, for example) applied directly or indirectly through intervening body parts is used to break the solid matter into pieces. The solid matter may be an abnormal byproduct of a biological function or a foreign body. The pieces of solid matter are not taken out but are eliminated or absorbed through normal biological functions.
Examples: Extracorporeal shockwave lithotripsy, cystoscopy with fragementation of bladder neck calculus

 

The second group of root operations we are going to address are the two procedures that involve only examination of body parts and regions.

 

Inspection (J) Definition: Visually and/manually exploring a body part
Explanation: Visual exploration may be performed with or without optical instrumentation. Manual exploration may be performed directly or through intervening body layers.

Coding Guideline: Discontinued procedures (B3.3)

 

If the intended procedure is discontinued, code the procedure to the root operation performed. If a procedure is discontinued before any other root operation is performed, code the root operation by inspection of the body part or anatomical region inspected.

 

Example: A planned aortic valve replacement procedure is discontinued after the initial thoracotomy, but before any incision is made in the heart muscle, when the patient becomes hemodynamically unstable. This procedure is coded as an open inspection of the mediastinum.

 

Coding Guideline Inspection Procedures

 

(B3.11a)
Inspection of a body part(s) performed in order to achieve the objective of a procedure is not coded separately.

 

Example: For a fiberoptic bronchoscopy performed for irrigation of bronchus, only the irrigation procedure is coded.

(B3.11b)
If multiple tubular body parts are inspected, the most distal body part inspected is coded. If multiple non-tubular body parts in a region are inspected, the body part specifying the entire inspected area is coded.

 

Examples: Cystoureteroscopy with inspection of bladder and ureters is coded to the ureter body part value. Exploratory laparotomy with general inspection of abdominal contents is coded to the peritoneal cavity body part value.

 

(B3.11c)
When both an inspection procedure and another procedure are performed on the same body part during the same episode, if the inspection procedure is performed using a different approach than the other procedure, the inspection is coded separately.

 

Example: Endoscopic inspection of the duodenum is coded separately when open excision of the duodenum is performed during the same procedural episode.
Map (K) Definition: Locating the route of passage of electrical impulses and/or locating functional areas in a body part
Explanation: Applicable only to the cardiac conduction mechanism and the central nervous system
Examples: Cardiac mapping, cortical mapping

 

Our next group of procedures to explore includes procedures that alter the diameter or route of a tubular body part.

About the Author

Becky DeGrosky, RHIT, is the Product Manager for TruCode. She brings over 35 years experience in health information management.  She worked for 11 years in HIM software development for QuadraMed and MedAssets, including product management, content maintenance, implementation and training, and client support.  She is an active member of the Pennsylvania Health Information Management Association, where she has served on multiple committees including Chairman of the Education Committee and the Coding Roundtable.

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Rebecca DeGrosky, RHIT

Becky DeGrosky, RHIT, is the Product Manager for TruCode. She brings over 35 years experience in health information management.  She worked for 11 years in HIM software development for QuadraMed and MedAssets, including product management, content maintenance, implementation and training, and client support.  She is an active member of the Pennsylvania Health Information Management Association, where she has served on multiple committees including Chairman of the Education Committee and the Coding Roundtable.