September 4, 2011

To Decipher the ICD-10-PCS Root Operations, Learn the Definitions

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In the ICD-10 procedural coding system (PCS), identifying the root operation— the third character in the PCS code—is integral to assigning codes. This character defines the “objective” of the procedure, and 31 root operations are included in the medical and surgical section of the PCS.

While some of the terms are similar to ICD-9-PCS, the definitions differ except in a few cases (such as the following terms: resection, excision and removal). It is important for coders to understand the differences between the root operations, which can be divided into nine categories.  Each category has several terms with specific definitions.

Per CMS guidelines, it is the coder’s responsibility to determine what the documentation in the medical record equals in the PCS definitions.  The physician is not expected to use the terms that are in the PCS code descriptions.  As such, learning the definitions of these terms and being able to apply them to the physician documentation is an important part of a coder’s ICD-10 PCS education.

The rest of this article separates the root operations by category and then lists the Centers for Medicare & Medicaid Services’ definitions of each operation.

Root Operation: Removing Some or All of a Body Part

  • Excision—cutting out or off, without replacement, a portion of the body part
  • Resection—cutting out or off, without replacement, all of a body part
  • Detachment—cutting off all or part of the upper or lower extremities
  • Destruction—the physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent
  • Extraction—the pulling or stripping out or off all or a portion of a body part by the use of force.

Root Operation: Removing Solids, Fluids, or Gases

  • Drainage—taking or letting out fluids and/or gases from a body part
  • Extirpation—taking or cutting out solid matter from a body part (i.e., foreign body)
  • Fragmentation—breaking solid matter in a body part into pieces.

Root Operation: Cutting or Separating a Body Part

  • Division—cutting into a body part without draining fluids and/or gases in order to separate or transect a body part
  • Release—freeing a body part from an abnormal physical constraint by cutting or using force

Root Operation: Putting In, Putting Back or Moving Some or All of a Body Part

  • Transplantation—putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part
  • Reattachment—putting back in or on all or a portion of a separated body part to its normal location or other suitable location
  • Transfer—moving, without taking out, all or a portion of a body part to another location to take over its function
  • Reposition—moving all or a portion of a body part to its normal location or other suitable location

 


 

Route Operation: Altering the Diameter or Route of a Tubular Body Part

  • Restriction—partially closing an orifice or the lumen
  • Occlusion—completely closing an orifice or the lumen
  • Dilation—expanding an orifice or the lumen
  • Bypass—altering the route of passage of the contents

Route Operation: Use of a Device

  • Insertion—putting in a non-biological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part
  • Replacement—putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part
  • Supplement—putting in or on biologic or synthetic material that physically reinforces and/or augments the function of a portion of a body part
  • Change—taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane
  • Removal—taking out or off a device from a body part
  • Revision—correcting, to the extent possible, a malfunctioning or displaced device

Route Operation: Examination Only

  • Inspection—visually and/or manually exploring a body part
  • Map—locating the route of passage of electrical impulses and/or locating functional areas in a body part

Route Operation: Other Repairs

  • Control—Stopping, or attempting to stop, post-procedural bleeding
  • Repair—restoring, to the extent possible, a body part to its normal anatomic structure and function

Route Operation: Other Objectives

  • Fusion—joining together portions of an articular body part and rendering it immobile
  • Alteration—modifying the natural anatomic structure of a body part without affecting its function
  • Creation—making a new genital structure that does not physically take the place of a body part

Peggy Hapner is manager of the HIM consulting division at Medical Learning Inc. (MedLearn), St. Paul, MN.

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