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Root Operations for ICD-10 PCS
Root Operations for ICD-10-PCS -- all 31 root operations with defintions and examples
Terms in this set (31)
0 - Alteration
Modifying the natural anatomic structure of a body part without affecting the function of the body part.
Purpose to improve appearance
Examples: Face lift, breast augmentation
1 - Bypass
Altering the route of passage of the contents of a tubular body part.
Examples: Coronary artery bypass, colostomy formation
2 - Change
Taking out of 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.
All CHANGE procedures are coded used an EXTERNAL approach
Example: Urinary catheter change, gastrostomy tube change
3 - Control
Stopping or attempting to stop, postprocedural bleeding.
The site of the bleeding is coded as an anatomical region and not to a specific body site
Example: Control of post-prostatectomy hemorrhage, control of post-tonsillectomy hemorrhage
4 - Creation
Making a new genital structure that does not take over the function of a body part.
Used only for sex change operations
5 - Destruction
Physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent.
None of the body part is physically taken out
Example: Fulguration of rectal polyp, cautery of skin lesion
6 - Detachment
Cutting off all or part of the upper or lower extremities.
The body part value is the site of the detachment, with a qualifier to further specify the level where the extremity was detached.
Examples: Below knee amputation, disarticulation of shoulder
7 - Dilation
Expanding an orifice or the lumen of a tubular body part
The orifice can be natural or artifically created. Accomplished by stretching a tubular body part using intraluminal pressure or by cutting part of the orifice or wall of the tubular body part.
Examples: Percutaneous transluminal angioplasty, pyloromyotomy
8 - Division
Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part.
All or a portion of the body part is separated into two or more portions.
Examples: Spinal cordotomy, osteotomy
9 - Drainage
Taking or letting out fluids and/or gases from a body part.
The qualifier "diagnostic" is used to identify drainage procedures that are biopsies.
Examples: Thoracentesis, incision and drainage
B - Excision
Cutting out of off, without replacement, a portion of a body part.
The qualifier "diagnostic" is used to identify procedures that are biopsies.
Examples: Partial nephrectomy, liver biopsy
C - Extirpation
Taking or cutting out solid matter from a body part.
The solid matter may be an abnormal byproduct of a biological function or a foreign body; it may be imbedded in a body part or in the lumen of a tubular body part. The solid matter may or may not have been previously broken into pieces.
Examples: Thrombectomy, choledocholithotomy, endarterectomy
D - Extraction
Pulling or stripping out or off all or a portion of a body part by the use of force.
The qualifier Diagnostic is used to identify extractions that are biopsies.
Examples: Dilation and currettage, vein stripping
F - Fragmentation
Breaking solid matter ina body part into pieces.
Physical frce (eg manual, ultrasonic) applied directly or indirectly throuh intervening body parts are used to break the solid matter into pieces. The solid matter may be abnormal byproduct of a biological function or a foreign body. The pieces of solid matter are not taken out, but are sliminated or absorbed through normal biological functions.
Examples: Extracorporeal shockwave lithotripsy, transurethral lithotripsy
G - Fusion
Joining together portions of an articular body part, rendering the articular body part immobile.
The body part is joined together by fixation device, bone graft, or other means.
Examples: Spinal fusion, ankle arthrodesis
H - Insertion
Putting in a nonbiological applicance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part.
Example: Insertion of radioactive implant, insertion of central venous catheter
J - Inspection
Visually and/or manually exploring a body part.
Visual exploration may be performed with or without optical instrumentation. Manual exploration may be performed directly or through intervening body layers.
Examples: Diagnostic arthroscopy, exploratory laparotomy
K - Map
Locating the route of passage of electrical impulses and/or location functional areas of a body part.
Applicable only to cardiac conduction mechanism and the central nervous system.
Examples: cardiac mapping, cortical mapping
L - Occlusion
Completely closing an orifice or lumen of a tubular body part.
The orifice can be natural or artificially created.
Examples: fallopian tube ligation, ligation of inferior vena cava
M - Reattachment
Putting back in or on all or a portion of a separated body part to its normal location of other suitable location.
Vascular circulation and nervous pathways may or may not be reestablished.
Examples: reattachment of hand, reattachment of avulsed kidney
N - Release
Freeing of a body part from an abnormal physical constraint by cutting or by use of force.
Some of the restraining tissue may be taken out but none of the body part is taken out.
Examples: Adhesiolysis, carpal tunnel release
P - Removal
Taking out of off a device from a body part.
If a device is taken out a similar device put in without cutting or puncturing the skin or mucous membrance, the procedure is coded to the root operation CHANGE. otherwise, the procedure for taking out the device is coded to the root operation REMOVAL and the procedure for putting in the new device is coded to the root operation performed.
Examples: Drainage tube removal, cardiac pacemaker removal
Q - Repair
Restoring, to the extent possible, a body part to its normal anatomic structure and function
Used only when the method to accomplish the repair is not one of the other root operations.
Examples: Colostomy takedown, herniorrhage, suture of laceration
R - Replacement
Putting in or on a biological or synthetic material that physically takes the place and/or function of all or a portion of a body part
The body part may have been taken out or replace, or may be taken out, physically eradicated, or rendered nonfunctional during the REPLACEMENT procedure. A REMOVAL procedure is coded for taking out the device used in a previous replacement procedure.
Examples: total hip replacement, free skin graft
S - Reposition
Moving to its normal location or other suitable location all or a portion of a body part.
The body part is moved to a new location from an abnormal location, or from a normal location where it is not functions correctly. The body part may or may not be cut out of off to be moved to the new location.
Example: reposition of undescended testicle, fracture reduction
T - Resection
Cutting out or off, without replacement, all of a body part.
Examples: total nephrectomy, total lobectomy of the lung
V - Restriction
Partically closing an orifice or th elumen of a tubular body part.
The orifice can be natural or artificially created.
Examples: Esophagogastric fundoplication, cervical cerclage
W - Revision
Correcting, to the extent possible, a portion of a malfunctioning device or the position of a displaced device.
Revision can include correcting a malfunctioning or displaced device by taking out or putting in components of the device such as a screw or pin.
Examples: Adjustment of position of pacemaker lead, recementing of hip prothesis
U - Supplement
Putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part.
The biological material is non-living, or is living and from the same individual. The body part may have been previously replaced, and the SUPPLEMENT procedure is prerformed to physically reinforce and/or augment the function of the replaced body part.
Examples: Herniorrhaphy using mesh, free nerve graft, mitral valve ring annuloplasty, put a new acetabular liner in a previous hip replacement.
X - Transfer
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
The body part transferred remains connected to its vascular and nervous supply.
Examples: Tendon transfer, skin pedicle flap transfer
Y - 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
The native body part may or may not be taken out, and the transplanted body part may take over all or a portion of its function.
Kidney transplant, heart transplant
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