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ICD 10 PCS Root Operations

Terms in this set (35)

Excision
The cutting out/off without replacement, SOME of a body part. Note - when Excision is performed for a biopsy, the qualifier "X" is used to indicate Diagnostic.
Resection
The cutting out/off without replacement, ALL of a body part.
Detachment
The 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.
Extirpation
Taking or cutting out solid matter from a body part.
Drainage
Taking or letting out fluids and/or gases from a body part. Note - the qualifier Diagnostic is used to identify drainage procedures that are biopsies.
Fragmentation
Breaking solid matter in a body part into pieces.
Division
The cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part.
Release
Freeing a body part from an abnormal physical constraint by cutting or by use of force.
Transplantation
The 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
The putting back in or on all or a portion of a separated body part to its normal location or other suitable location. Note - the body part doesn't have to function.
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. Note - free grafts are NOT transfers (see Replacement) because they are removed from the vascular bed. In transfers, the graft stays attached to the vascular bed and is moved over.
Note - the body system value describes the deepest tissue layer in the flap and the qualifier can indicate the other tissue layers, if any, being transferred.
Reposition
Moving to its normal location or other suitable location all or a portion of a body part. (Fracture reduction) Note - the body part is moved to a new location from an abnormal location, or from a normal location where it is not functioning correctly. Note - the body part may or may not be cut out or off to be moved to the new location. Note - The application of a cast or splint in conjunction with the Reposition procedure is NOT coded separately.
Restriction
Partially closing an orifice or the lumen of a tubular body part. Note - the orifice can be a natural or an an artificially created orifice. Note - When the objective of the procedure is to NARROW the diameter of a tubular body part or orifice, it is coded to Restriction. Note - includes intraluminal and extraluminal methods.
Occlusion
Completely closing an orifice or the lumen of a tubular body part. Note - includes both intraluminal and extraluminal methods. Note - division of the tubular body part prior to closing it is an integral part of the Occlusion procedure. Note - If the objective of an embolization procedure is to completely close a vessel, the root operation Occlusion is coded. If the objective of an embolization procedure is to NARROW the lumen of a vessel, the root operation Restriction is coded.
Dilation
Expanding an orifice or the lumen of a tubular body part. Accomplished by stretching a tubular body part using intraluminal pressure or by cutting part of the orifice or wall of the tubular body part. Note - a device placed to maintain the new diameter is an integral part of the Dilation procedure, and is coded to a 6th character device value. Note - the coronary arteries are classified as a single body part that is further specified by number of sites treated and not by name or number of arteries.
Bypass
Altering the route of passage of the content of a tubular body part. Rerouting content 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. Includes one or more anastomoses, with or without the use of a device.
Insertion
Putting in a non-biological device that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part. Note - represents those procedures where the sole objective is to put in a device WITHOUT doing anything else to 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. Note - the body part may have been taken out or replaced, or may be taken out, physically eradicated, or rendered nonfunctional during the Replacement procedure. Note - a Removal procedure is coded for taking out the device used in a previous replacement procedure. Note - taking out the body part is included. Note - when a mastectomy is performed and a TRAM procedure is performed subsequently in the same operative episode, the mastectomy is NOT coded separately and is considered integral to the TRAM procedure.
Supplement
Putting in or on biologic or synthetic material that physically reinforces and/or augments the function 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 performed to physically reinforce and/or augment the function of the replaced body part. Note - Herniorrhaphy with mesh is coded to Supplement, however herniorrhaphy WITHOUT mesh is coded to Repair. Note - Do NOT physically take the place of the existing 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. Note - ALL Change procedures are coded using the EXTERNAL approach only. Note - only includes procedures where a similar device is exchanged WITHOUT making a new incision or puncture. Note - general body part values are used when the specific body part value is not in the table.
Removal
Taking out or off a device from a body part. Note - if a similar device is put in without cutting or puncturing the skin or mucous membrane, the procedure is coded to the root operation Change. Note - A procedure to remove a device is coded to Removal if it is not an integral part of another root operation.
Revision
Correcting, to the extent possible, a malfunctioning or displaced device. Note - revision can include correcting a malfunctioning device by taking out and/or putting in part of the device. Note - Revision is coded when the objective of the procedure is to correct the positioning or function of a previously placed device, without taking the entire device out and putting a whole new device in its place. A complete re-do of the original root operation is coded to the root operation that is performed.
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. Note - the root operation Inspection represents procedures where the sole objective is to examine a body part. Procedures that are discontinued without any other root operation being performed are also coded to Inspection. Note - inspection of a body part(s) performed in order to achieve the objective of a procedure is not coded separately. Note - if multiple tubular body parts are inspected, the most distal body part inspected is coded. If multiple non-tubular body parts in a region are inspected, the body part that specifies the entire area inspected is coded. Note - when both an inspection procedure and another procedure are performed on the same body part during the same episode, if the inspection procedure is performed using a different approach than the other procedure, the Inspection procedure is coded separately.
Map
Locating the route of passage of electrical impulses and/or locating functional areas in a body part. Note - applicable only to the cardiac conduction mechanism and the central nervous system.
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. Note - If Bypass, Detachment, Excision, Extraction, Reposition, Replacement or Resection are performed to control the bleed then the procedure is coded to the root operation performed and NOT Control. Note - Control includes irrigation or evacuation of hematoma done at an operative site.
Repair
Restoring, to the extent possible, a body part to its normal anatomic structure and function. Note - used only when the method to accomplish the repair is not one of the other root operations. Note - represents a broad range of procedures for restoring the anatomic structure of a body part such as suture of lacerations. Note - also functions as the NEC root operation.
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. Note - only a limited range of procedures is represented in the root operation Fusion, because fusion procedures are by definition only performed on the joints. Note - the approach and the column are identified by the 7th character qualifier. Note - when an interbody device is used, it trumps all other values for the device value. Note - If bone graft is the only device used used to render the joint immobile, the device value Nonautologous Tissue Substitute or Autologous Tissue substitute is used. Note - If a mixture of autologous and nonautologous bone graft is used, code the device value to Autologous Tissue Substitute. Note - when bone is harvested for graft, this can be coded separately to excision EXCEPT for when they used bone from the laminectomy to get to the operative site. Note - when an interbody fusion is followed by insertion of a pedicle screw stabilization procedure, the stabilization procedure is coded to the root operation Insertion, separately.
Alteration
Modifying the natural anatomic structure of a body part without affecting the function of the body part. The principal purpose is to improve appearance. "Cosmetic" procedures.
Creation
Making a new genital structure that does not physically take the place of a body part. Used only for sex change operations. Note - if a separate procedure is performed to harvest autograft tissue, it is coded to the appropriate root operation in addition to the primary procedure.
PTCA without Thrombectomy
The objective of the procedure is to widen the diameter of the coronary arteries to increase blood flow and is coded to Dilation. Note - if a stent is deployed and left in place, it is coded in the device character. If more than one site is treated and a combination of characters from the device value are used, those are sites are coded separately. PTCA with a bare metal stent to one site in conjunction with a drug eluting stent to another site will require two codes.
Intraluminal Thrombectomy
The objective of the procedure is to remove the plaque from within the lumen of the vessel and is coded to Extirpation. PTCA in conjunction with a thrombectomy would require multiple codes. At least one for the PTCA and an additional code for the thrombectomy.
Total Hip Arthroplasty
The objective of the procedure is to replace the malfunctioning or deteriorating joint and is coded to Replacement. The bearing surface is identified in the device character. Note - When Replacement is being performed on a joint, the body system is either the Upper or Lower joints.
Chest Tube
The objective of the procedure is to insert a device and is coded to Insertion. Note - the pleural cavity is located in the General anatomy body system.
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