This is the sixth article in a series addressing the definitions and differences between the Medical & Surgical root operations of ICD-10-PCS. As in previous articles, let’s review what we have covered so far.
In the Medical and Surgical section (first character 0), there are 31 root operations with standardized terminology and no procedure names, no diagnostic information, and no eponyms. So far, we have covered 24 of them, and today will bring us to the remaining ones. We have gone over the notion that a fracture reduction is the root operation reposition, and that there is no appendectomy listing in ICD-10-PCS. Coders will need to know that the cutting out or off, without replacement, of all of a body part is a Resection. Since an appendectomy typically involves the total removal of the appendix, Resection is the correct root operation. This is the type of determination the coder must make in order to ensure accurate code assignment.
Coders will find this information and more in the ICD-10-PCS book Appendix A and B. The PCS appendices are rich with helpful information intended to assist coders in the translation of medical procedures to the new code set. That is for future discussion, however, as today we are focusing on the procedures involving cutting or separation only (“only” meaning that nothing is being removed). As in the ICD-10-PCS book, we will review the definition, explanation, and some examples of each. We also will introduce the applicable coding guidelines. The character listed after each root operation represents the third character in the PCS code.
Let’s begin with Procedures Involving Cutting or Separation Only, where we find there are two root operations. They include:
Definition: Cutting into a body part, without draining fluids and/or gases from the body part, in order to separate or transect a body part.
Explanation: All or a portion of the body part is separated into two or more portions.
Examples: Spinal cordotomy, osteotomy, neurotomy, EGD with esophagotomy of esophagogastric junction.
Coding Guideline: Release vs. Division (B3.14)
If the sole objective of the procedure is freeing a body part without cutting the body part, the root operation is Release. If the sole objective of the procedure is separating or transecting a body part, the root operation is Division.
Examples: Freeing a nerve root from surrounding scar tissue to relieve pain is coded to the root operation Release. Severing a nerve root to relieve pain is coded to the root operation Division.
Definition: Freeing a body part from an abnormal physical constraint by cutting or by use of force.
Explanation: Some of the restraining tissue may be taken out, but none of the body part is taken out.
Examples: Peritoneal adhesiolysis, carpal tunnel release, frenulotomy for treatment of tongue tie syndrome.
Coding Guidelines: Release Procedures (B3.13)
In the root operation Release, the body part value coded is the body part being freed, not the tissue being manipulated or cut to free the body part.
Example: Lysis of intestinal adhesions is coded to the specific intestine body part value.
Our next group is Procedures That Define other Repairs, which has been divided into two root operations. They include:
Definition: Stopping or attempting to stop post-procedural bleeding.
Explanation: The site of the bleeding is coded as an anatomical region and not to a specific body part.
Examples: Control of post-prostatectomy hemorrhage, control of post-tonsillectomy hemorrhage, hysteroscopy with cautery of post-hysterectomy oozing and evacuation of clot.
Coding Guidelines: Control vs. more definitive root operations (B3.7)
The root operation Control is defined as “stopping or attempting to stop post-procedural bleeding.” If an attempt to stop post-procedural bleeding is initially unsuccessful, and stopping the bleeding requires performing any of the definitive root operations Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then that root operation is coded Control.
Example: Resection of spleen to stop post-procedural bleeding is coded to Resection instead of Control.
Definition: Restoring, to the extent possible, a body part to its normal anatomic structure and function.
Explanation: Used only when the method to accomplish the repair is not one of the other root operations.
Examples: Colostomy takedown, herniorrhaphy, suture of laceration, perineoplasty with repair of old obstetric laceration.
Coding Guidelines: Overlapping body layers (B3.5)
If the root operations Excision, Repair or Inspection are performed on overlapping layers of the musculoskeletal system, the body part specifying the deepest layer is coded.
Example: Excisional debridement that includes skin, subcutaneous tissue and muscle is coded to the muscle.
Our final group of root operations is Procedures That Define Objectives, where we find the following three operations:
Definition: Modifying the natural anatomic structure of a body part without affecting the function of the body part.
Explanation: Principal purpose is to improve appearance.
Examples: Face lift, breast augmentation, procedures performed for cosmetic purposes.
As of the publication of the October 2012 coding guidelines, there was no guidance addressing the root operation of Alteration.
Definition: Making a new genital structure that does not take over the function of the body part.
Explanation: Used only for sex-change operations.
Examples: Creation of vagina in a male, creation of penis in a female.
As of the publication of the October 2012 coding guidelines, there was no guidance addressing the root operation of Creation.
Definition: Joining together portions of an articular body part, rendering the articular body part immobile.
Explanation: The body part is joined together by fixation device, bone graft, or other means.
Examples: Spinal fusion, ankle arthrodesis.
Coding Guidelines: Fusion procedures of the spine (B3.10a, B3.10b, and B3.10c)
The body part coded for a spinal vertebral joint(s) rendered immobile by a spinal fusion procedure is classified by the level of the spine (i.e. thoracic). There are distinct body-part values for a single vertebral joint and for multiple vertebral joints at each spinal level.
Example: Body part values specify Lumbar Vertebral Joint, Lumbar Vertebral Joints, 2 or More, and Lumbosacral Vertebral Joint.
If multiple vertebral joints are fused, a separate procedure is coded for each vertebral joint that uses a different device and/or qualifier.
Example: Fusion of lumbar vertebral joint, posterior approach, anterior column; and fusion of lumbar vertebral joint, posterior approach, posterior column are coded separately.
Combinations of devices and materials often are used on a vertebral joint to render the joint immobile. When combinations of devices are used on the same vertebral joint, the device value coded for the procedure is as follows:
• If an inter-body fusion device is used to render the joint immobile (alone or containing other material, such as a bone graft), the procedure is coded with the device value Interbody Fusion Device.
• If bone graft is the only device used to render the joint immobile, the procedure is coded with the device value Nonautologous Tissue Substitute or Autologous Tissue Substitute.
• If a mixture of autologous and nonautologous bone graft (with or without biological or synthetic extenders or binders) is used to render the joint immobile, code the procedure with the device value Autologous Tissue Substitute.
Fusion of a vertebral joint using a cage-style, inter-body fusion device containing morsellized bone graft is coded to the device Inter-body Fusion Device.
Fusion of a vertebral joint using a bone dowel inter-body fusion device made of cadaver bone and packed with a mixture of local morsellized bone and demineralized bone matrix is coded to the device Interbody Fusion Device.
This brings us to the conclusion of our exploration of the root operations in the Medical & Surgical Section of ICD-10-PCS. Although certainly the largest and most frequently used section, there are 10 additional sections, each with its own group of root operations. Our journey is not over yet. Best wishes for great coding with ICD-10-CM/PCS.
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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