September 29, 2011

Medical and Surgical Root Operations: Procedures that Put In/Put Back or Move Some/All of a Body Part

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EDITOR’S NOTE: This is the second in a series of articles addressing the definitions and differences between the medical and surgical root operations.

 

Our focus today is the four root operations that put in/put back or move some or all of a body part. As per the ICD-10-PCS book, we will review the definitions, explanations and some examples of each. We also will introduce the coding guidelines applicable to these procedures.

Transplantation (Y)

Definition:  Putting in or on all or a portion of a living body part taken from another individual or animal to take the place and/or function of all or a portion of a similar body part.

Explanation:       The native body part may or may not be taken out, and the transplanted body part may take over all or a portion of the original part’s function.

Examples: Kidney transplant, heart transplant

Coding Guideline: Transplantation vs. Administration (B3.16)

Putting in a mature and functioning living body part taken from another individual or animal is coded to the root operation of transplantation. Putting in autologous or nonautologous cells is coded to the administration section. For example, putting in autologous or nonautologous bone barrow, pancreatic islet cells or stem cells is coded to administration.

Reattachment (M)

Definition:  Putting back in or on all or a portion of a separated body part, affixing it to its normal location or another suitable location.

Explanation: Vascular circulation and nervous pathways may or may not be reestablished.

Examples:  Reattachment of hand, replantation of avulsed scalp, closed replantation of three avulsed teeth.

Transfer (X)

Definition:  Moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part.

Explanation: The body part transferred remains connected to its vascular tissue and nervous supply.

Examples: Tendon transfer, skin pedicle flap transfer, trigeminal-to-fascial nerve transfer, percutaneous endoscopic

Reposition (S)

Definition:  Moving all or a portion of a body part to its normal location or another suitable location.

Explanation: The body part is moved to a new location from an abnormal location, or away from a normal location where it is not functioning correctly. The body part may or may not be cut out or off to be moved to the new location.

Examples:  Reposition of undescended testicle, fracture reduction

Coding Guideline:  Reposition for fracture treatment (B3.15)

Reduction of a displaced fracture is coded to the root operation of reposition, and the application of a cast or splint in conjunction with the reposition procedure is not coded separately.  Treatment of a nondisplaced fracture is coded to the procedure performed.

For example, putting a pin in a nondisplaced fracture is coded to the root operation of insertion. Casting of a nondisplaced fracture is coded to the root operation of immobilization in the placement section.

 


 

As you can see from review of this group of medical and surgical root operations, not all of the language should be foreign to a physician. In the above group of procedures, the only term that will require coder translation is “reposition.” The documentation in the record will continue to indicate an open reduction, internal fixation or ORIF, and the coder will need to translate to “reposition” as the root operation.

Our next group of procedures to explore is those that take out or eliminate solid matter, fluids or gases from a body part, actions that include the root operations of drainage, extirpation and fragmentation. We also will focus on the group of procedures that involve only examination of body parts and regions: inspection and map.

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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Read 218 times Updated on September 23, 2013
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.