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Root Operations

Terms in this set (95)

Structure of ICD-10-PCS
Section, Body System, Root operation, Body Part, Approach, Device, Qualifier
Alteration
Modifying the natural anatomic structure of a body part without affecting the function of the body part Explanation: Principle Purpose is to improve appearance. eg. Face lift; breast augmentation
Bypass
Altering the route of passage of the contents of a tubular body part. Rerouting contents of a body part to a downstream area of the normal route, to a similar route and body part, or to an abnormal route and dissimilar body part. eg. Coronary artery bypass: eg. Anastomosis; Colostomy, bypass colon; Diversion.
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. All CHANGE procedures are coded using the approach EXTERNAL. eg..Urinary catheter change; gastrostomy tube change.
Control
Stopping, or attempting to stop, post procedural bleeding. The site of the bleeding is coded as an anatomical region and not to a specific body part eg. Control of post-prostatectomy hemorrhage; control of post-tonsillectomy hemorrhage.
Creation
Making a new genital structure that does not take over the function of a body part. Used only for sex change operations eg. Creation of vagina in a male; creation of penis in a female
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. eg. Fulguration of rectal polyp; cautery of skin lesion; Cauterization; Coagulation; Crushing, nerve; Cryotherapy; Cryoablation; Denervation;
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 if applicable, to further specify the level where the extremity was detached. eg. Below knee amputation; Disarticulation of shoulder; Amputation (extremity).
Dilation
Expanding an orifice or the lumen of a tubular body part. The orifice can be a natural orifice or an artificially created orifice. Accomplished by stretching a tubular body part using intraluminal pressure or by cutting part of the orifice or wall of the tubular body part. eg.Percutaneous transluminal angioplasty; pyloromyotomy; Angioplasty.
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. eg. Spinal cordotomy; osteotomy.
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. eg. Thoracentesis; incision and drainage.
Excision
Cutting out or off without replacement, a portion of a body part. The qualifier DIAGNOSTIC is used to identify excision procedures that are biopsies. eg. Partial nephrectomy, liver biopsy.
Extirpation
Taking or cutting out solid mater from a body part. The solid matter may be an abnormal byproduct of biological function or a foreign body. eg. Thrombectomy; choledocholitotom; Calculus removal; Embolectomy; Endarterectomy; Evacuation, hematoma.
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. eg. Dilation and curettage; vein stripping; Low-transverse C-section.
Fragmentation
Breaking solid matter in a body part into pieces. Physical force applied directly or indirectly is used to break the solid matter into pieces. eg. (ESWL) Extracorporeal shockwave lithotripsy; transurethral lithotripsy.
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. eg. Spinal fusion; ankle arthrodesis.
Insertion
Putting in a nonbiological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part. eg. Insertion of radioactive implant; insertion of central venous catheter.
Inspection
Visually and or manually exploring a body part. Visual exploration may be performed with or without optical instrumentation. eg. Diagnostic arthroscopy; exploratory laparotomy.
Map
Locating the route of passage of electrical impulses and/or locating functional areas in a body part. Applicable only to cardiac conduction mechanism and central nervous system. eg. Cardiac mapping, cortical mapping.
Occlusion
Completely closing an orifice or lumen of a tubular body part. The orifice can be a natural orifice or an artificially created orifice. eg. Fallopian tube ligation; ligation of inferior vena cava; Closure; Embolization.
Reattachment
Putting back in or on, all ,or a portion of a separated body part, to its normal location or suitable location. Vascular circulation and nerve pathways may or may not be reestablished. eg. Reattachment of hand; reattachment of avulsed kidney
Release
Freeing 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. eg. Adhesiolysis; carpal tunnel release
Removal
Taking out or off a device from a body part. If a device is taken out and a similar device put in without cutting or puncturing the skin, the procedure is coded to the root operation CHANGE otherwise it is coded REMOVAL. eg. Drainage tube removal; cardiac pacemaker removal.
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 one of the other root operations. eg. Colostomy takedown; herniorrhaphy; suture of laceration.
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 replaced, 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. eg.Total hip replacement; bone graft; free skin graft.
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 functioning correctly. eg. Reposition of undescended testicle; fracture reduction; Advancement (flap); Blepharoplasty; Elevation, bone fragments, skull.
Resection
Cutting out or off, without replacement all of a body part. eg.Total nephrectomy; total lobectomy of lung.
Restriction
Partially closing an orifice or the lumen of a tubular body part. The orifice can be a natural orifice or an artificially created orifice. eg. Esophagogastric fundoplication; cervical cerclage.
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. eg. Adjustment of position of pacemaker lead; recementing of hip prosthesis.
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 nonliving, or is living and from the same individual. The body part may have been previously replaced, and the SUPPLEMENT procedure is performed to physically reinforce and or augment the function of the replaced body part. eg. Herniorrphaphy using mesh; free nerve graft; mitral valve ring annuloplasty; put a new acetabular liner in a previous hip replacement.
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. eg. Tendon transfer; skin pedicle flap transfer.
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. eg. Kidney transplant; heart transplant.
Procedures That Take Out Some or All of a Body Part---The TAKEOUT Group
Excision, Resection, Extraction, Destruction, Detachment
Excision (B)
Cutting out or off Some of a body part Without replacing body part. eg. Breast lumpectomy
Resection (T)
Cutting out or off All of a body part Without replacing body part. eg. Total nephrectomy
Extraction (D)
Pulling out or off All or a portion of a body part Without replacing body part. eg. Suction D&C
Destruction (5)
Eradicating All or a portion of a body part Without taking out or replacing body part eg. Rectal polyp fulguration
Detachment (6)
Cutting out or off Extremity only, any level Without replacing extremity. eg Below the knee amputation
Procedures That Put In/ Put Back or Move Some/ All of A Body Part-----The MOVING Group
Transplantation, Reattachment, Reposition, Transfer
Transplantation (Y)
Putting in All or a portion of a living body part from other individual or animal. Physically takes the place and or function of all or a portion of a similar body part. eg. Heart transplant,
Reattachment (M)
Putting back in or on all or a portion of a separated body part. Put in its normal or suitable location eg. Finger
Reposition (S)
Moving All or a portion of a body part. Moving to its normal or suitable location eg.Reposition undescended testicle
Transfer (X)
Moving All or a portion of a body part without taking out body part. eg.Tendon transfer; skin transfer flap.
Procedures That Take Out or Eliminate Solid Matter, Foods, or Gases from the Body....The GUNK Group
Drainage, Extirpation, Fragmentation,
Drainage (9)
Taking or letting out Fluids and or gases from a body part Without taking any of the body part. The qualifier DIAGNOSTIC is used to identify drainage procedures that are biopsies. eg Incision and drainage
Extirpation (C)
Taking or cutting out Solid matter in a body part without taking any of the body part.. The solid matter may be an abnormal byproduct of biological function. eg Thrombectomy
Fragmentation (F)
Breaking into pieces Solid matter within a body part. The physical force applied directly or indirectly is used to break solid matter into pieces. eg.Lithotripsy
Procedures That Involve Only Examination of Body Parts and Regions........The EXAM Group
Inspection, Map
Inspection (J)
Visual and or manual exploration Some or all of a body part. Visual exploration performed with or without optical instrumentation. eg. Diagnostic arthroscopy; diagnostic cystoscopy
Map (K)
Locating route of passage of electrical impulses or functional areas In a body part Applicable only to cardiac conduction mechanism and central nervous system. eg Cardiac mapping
Procedures That Alter the Diameter/ Route of a Tubular Body Part---The TUBULAR Group
Bypass, Dilation, Occlusion, Restriction,
Bypass (1)
Altering the route of passage Contents of tubular body part. May include use of living tissue, nonliving biological material or synthetic material. eg Gastrojejunal bypass; coronary artery bypass
Dilation (7)
Expanding Orifice or lumen of tubular body part. Orifice may be natural or artificially created. eg. Percutaneous transluminal angioplasty
Occlusion (L)
Completely closing Orifice or lumen or tubular body part Orifice may be natural or artificially created Fallopian tube ligation
Restriction (V)
Partially closing Orifice or lumen of tubular body part. Orifice may be natural or artificially created. eg. Cervical cerclage; gastroesophageal fundoplication.
Procedures That Always Involve Devices...The DEVICE Group
Insertion, Replacement, Supplement, Removal, Change, Revision
Insertion (H)
Putting in or on-biological device In or on a body part. Putting in a non-biological device that monitors, assists, performs, or prevents a physical function but not physically take the place of a body part eg. Pacemaker insertion; central line insertion.
Replacement (R)
Putting in or on biological material, synthetic material, or living tissue taken from same induvial All or a portion of a body part Physically takes the place or function of all or all portion of a body part. Total hip replacement
Supplement (U)
Putting in or on a device that reinforces or augments A body part or a replaced body part Biological material is nonliving, or is living and form the same individual Herniorrhaphy using mesh
Removal (P)
Taking a device out or off A body part If anew device Is inserted via incision or puncture procedure is coded separately Cardiac pacemaker removal, central line removal
Change (2)
Taking a device out or off and putting back an identical or similar device In or on a body part Without cutting or puncturing skin Drainage tube change
Revision (W)
Correcting, to the extent possible, a malfunctioning or displaced device In or on a body part Correcting the position or function of a previous placed device Hip prosthesis adjustment, revision of pacemaker lead
Procedure involving cutting or separation only...The CUTTING Group
Division, Release
Division (8)
Cutting into/ separating A body part Without taking out any of the body part or draining fluids and or gases Osteotomy, neurology
Release (N)
Freeing, by cutting or by the use of the force A body part Freeing a body part from abnormal constraint without taking out any of the body part. Peritoneal adhesiolysis
Procedure that define other repairs---The REPAIR Group
Control, Repair
Control (3)
Stopping or attempting to stop Post procedural bleeding Limited to an anatomic regions not specific body parts Control of post prostatectomy
Repair (Q)
Restoring to the extent possible normal anatomic structure and function A body Part Used only when the method to accomplish the repair is not the one of the other root operations Hernia repair, suture laceration
Procedure that define other objectives.....The LEFTOVERS Group
Alteration, Creation, Fusion
Alteration (0/)
Modifying the natural anatomical structure A body part Without affecting function of the body part, performed for cosmetic purposes Face lift
Creation (4)
Making new anatomical structure Genital structure Does not physically take place of a body part, used only for sex operations Artificial vagina creation
Fusion (G)
Unification and immobilization Joint or articular body part Stabilization by fixation device, graft, and or other means Spinal fusion
Approaches in ICD-10-PCS
Open, Percutaneous, Percutaneous Endoscopic, Via Natural or Artificial Opening, Via Natural or Artificial Opening Endoscopic, Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance Approach, External
Open Approach
An open approach is defined as cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure. Procedures performed via an open approach have a fifth character value of 0. The access location for this approach is through either the skin or a mucous membrane; the type of instrumentation used is not applicable.
Coding Guideline Open Approach
ICD-10-PCS Draft Coding Guideline B5.1 states that procedures performed using the open approach with percutaneous endoscopic assistance are coded to the approach value 0, open. Therefore, the value of the fifth character of the code for a laparoscopic-assisted sigmoidectomy is 0.
Percutaneous Approach
A procedure performed via a percutaneous approach (character value 3) is one in which there is entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure. The access location for this approach is the skin or mucous membrane with nonvisualization instrumentation such as needles or catheters being used to reach the operative site.
Coding Guideline Percutaneous Approach
Coding Guideline B5.4a states that procedures performed via an indwelling device are coded to approach value 3, percutaneous. Fragmentation of kidney stone performed via percutaneous nephrostomy illustrates the use of this guideline, and the approach value for this procedure is 3.
Percutaneous Endoscopic Approach
Percutaneous endoscopic approach (character value 4) is defined as entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure. The access location for this approach is the skin or mucous membrane with visualization instrumentation being used to reach the operative site.
Via natural of artificial opening approach
An approach made via either a natural or artificial opening (character value 7) is defined as the entry of instrumentation through a natural or artificial external opening to reach the site of the procedure. The access location for this approach is an orifice with nonvisualization instrumentation being used to reach the operative site.
Via natural of artificial opening endoscopic approach
A via natural or artificial opening endoscopic approach (character value 8) is defined as the entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure. The access location for this approach is an orifice with visualization instrumentation being used to reach the procedure site.
Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance Approach
An approach made via natural or artificial opening with percutaneous endoscopic assistance (character value F) is defined as the entry of instrumentation through a natural or artificial external opening and entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to aid in the performance of the procedure.
Coding Guideline Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance Approach
Coding Guideline B5.2 states that procedures performed via natural or artificial opening with percutaneous endoscopic assistance are coded to approach value F. The code for a laparoscopic-assisted total vaginal hysterectomy is 0UT9FZZ, with the fifth character value of F.
External Approach
The external approach (character value X) is one in which the procedure is either performed directly on the skin or mucous membrane or indirectly by application of external force through the skin or mucous membrane.
Coding Guideline External Approach B5.3a
Coding Guideline B5.3a states that procedures performed within an orifice on structures that are visible without the aid of any instrumentation are coded to approach value X. An example using this guideline would be resection of the tonsils. This procedure would be coded with a fifth character value of X.
Coding Guideline B5.3b External Appproach
ICD-10-PCS Draft Coding Guideline B5.3b indicates that procedures performed indirectly by the application of external force through the intervening body layers are coded to approach value X. Therefore, when coding a closed reduction of a fracture, the fifth character of the code would be X.
Devices used in ICD-10-PCS
*Spoiler alert - the most commonly used device will be character Z - no device.
Things like clips, ligatures, or sutures are NOT considered devices in this section.
Autologous Device
Autologous - The donor and the recipient are the same person (example would be using a patient's own skin to do a skin graft)
Non Autologous Device
Nonautologous - The donor and the recipient are not the same person (example would be using donor skin to do a graft)
Synthetic Device
Synthetic - Material is not biologically derived (meaning it did not come from a living thing)
Intraluminal Device
Intraluminal - Situated within - introduced into the lumen (blood vessel)
Extraluminal Device
Extraluminal - Outside the lumen (blood vessel)
Device Coding Guideline B6.1a
B6.1a
A device is coded only if a device remains after the procedure is completed. If no device remains, the device value No Device is coded.
Device coding guideline B6.1b
B6.1b
Materials such as sutures, ligatures, radiological markers and temporary post-operative wound drains are considered integral to the performance of a procedure and are not coded as devices.
Device coding guideline B6.1c
B6.1c
Procedures performed on a device only and not on a body part are specified in the root operations Change, Irrigation, Removal and Revision, and are coded to the procedure performed.
Example: Irrigation of percutaneous nephrostomy tube is coded to the root operation Irrigation of indwelling device in the Administration section.
Drainage device
Device coding guideline B6.2
B6.2
A separate procedure to put in a drainage device is coded to the root operation Drainage with the device value Drainage Device.
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