procedure code definitions

STUDY
PLAY
alteration
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 augumentation, abdominoplasty for cosmetic reasons
bypass
definition: altering the route of passage of the contents of a tubular body part. explanation: rerouting the 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 parts, includes one or more anastomoses, with or without the use of a device. examples: coronary artery bypass, colostomy formation, femoral-popliteal artery bypass
change
definition: taking out or off a device from a body part and putting back an a identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane. explanation: all CHANGE procedures are coded using the approach EXTERNAL. examples: urinary catheter change, gastrostomy tube change, change of gastrostomy tube
control
definition: stopping, or attempting to stop, postprocedural bleeding. explanation: the side 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, control of post-operative peritoneal bleeding
creation
definition: making a new genital structure that does not take over the function of a body part. explanation: used only for sex change: examples: creation of vagina in a male, creation of a penis in a female,
Destruction
definition: physical eradication of all or a portion of a body part by the direct use of energy, force, ora destructive agent. explanation: none of the body part is physically taken out. examples: fulguration of rectal polyp, cautery of skin lesion, cautery of a nosebleed
detachment
definition: cutting off all or part of the upper or lower extremities. explanation: 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. examples: below knee amputation, disarticulation of shoulder, below elbow amputation
dilation
definition: expanding an orifice or the lumen of a tubular body part. explanation: 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. examples: percutaneous transluminal angioplasty, pyloromyotomy, ERCP with balloon dilation of common bile duct
division
definition: cutting into a body part without draining fluid 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 separate into two or more portions. examples: spinal cordotomy, osteotomy, neurotomy
drainage
definition: taking or letting out fluids and/ or gases from a body part. explanation: the qualifier diagnostic is used to identify drainage problems that are biopsies. examples: thoracentesis, incision and drainage,
excision
definition: cutting out or off, without replacement, a portion of a body part. explanation: the qualifier diagnostic is used to identify excision procedures that are biopsies. examples: partial nephrectomy, liver biopsy, biopsy, left kidney
extirpation
definition: taking or cutting out solid matter from a body part. explanation: the solid matter may be an abnormal by product 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 maynot have been previously broken into pieces. examples; thrombectomy, choledocholithotomy, endarterectomy, left common carotid endarterectomy
extraction
definition: pulling or stripping out or off all or a portion of a body part by the use of force. explanation: the qualifier diagnostic is used to identify extractions that are biopsies, examples: dilation and curettage, vein stripping, bone marrow biobsy
fragmentation
definition: breaking solid matter in a body part into pieces. explanation: Physical force (e.g., manual, ultrsonic) applied directly or indirectly through intervening body parts are used to break the solid matter into pieces. the solid matter may be an abnormal byproduct of a biological function or a foreign body. the pieces of solid matter are not taken out, but are eliminated or absorbed through normal biological functions. examples: extracorporeal shockwave lithotripsy, transurethral lithotripsy, transurethral cytoscopy with fragmentation of bladder calculus
fusion
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
insertion
definition: putting in a nonbiological appliance that monitors, assists, performs, or prevents a physological function but does not physically take the place of a body part. examples: insertion of radioactive implant, insertion of central venous catheter, insertion of cochlear implant
inspection
definition: visually and/or manually exploring a body part. explanation: 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, diagnostic colonoscopy
map
definition: locating the route of passage of electrical impulses and/ or locating functional areas in a body part. explanation: applicable only to the cardiac conduction mechanism and the central nervous system. examples: cardiac mapping, cortical mapping, intraoperative whole brain mapping
occlusion
definition: completely closing an orifice or lumen of a tubular body part. explanation: the orifice can be a natural orifice or an artificially created orifice. examples: fallopian tube ligation, ligation of inferior vena cava, percutaneous ligation of esophageal vein
reattachment
definition: putting back in or on all or a portion of a separated body part to its normal location or other suitable location. explanation: vascular circulation and nervous pathways may or may not be reestablished. examples: reattachment
of hand, reattachment of avulsed kidney, reattachment of severed ear
release
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: adhesiolysis, carpal tunnel release,
removal
definition: taking out or off a device from a body part. explanation: if a device is taken out and a similar device put in without cutting or puncturing the skin or mucous membrane, 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, cystoscopy with retrieval of right ureteral stent
repair
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, herniorrhapy, suture of laceration, suture of left biceps tendon laceration
replacement
definition: 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. explanation: 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. examples: total hip replacement, free skin graft,
reposition
definition: moving to its normal location or other suitable location all or a portion of a body part. explanation: the body part is moved to a new location from an abnormal location, or from a normal location where it is not fuctioning correctly. the body part may or may not be cut out or off to be moved to the new location. examples: reposition of undescended testicle, fracture reduction,
resection
definition: cutting out or off, without replacement, all of a body part. examples: total nephrectomy, total lobectomy of lung,
restriction
definition: partially closing an orifice or the lumen of a tubular body part. explanation: the orifice can be a natural orifice or an artificially created orifice. examples: esophagogastric fundoplication, cervical cerclage,
revision
definition: correcting to the extent possible, a portion of a malfunctioning device or the position of a displaced device. explanation: 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 prosthesis
supplement
definition: putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part. examples: hemiorrhaphy using mesh, free nerve graft, mitral valve ring annuloplasty, put a new acetabular liner in a previous hip replacement,
transfer
definition: 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. explanation: the body part transferred remains connected to its vascular and nervous supply. examples: tendon transfer, skin pedicle flap transfer, transfer radial to medial nerve
transplantation
definition: 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. explanation: 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 fuction. examples kidney transplant, heart transplant, liver transplant
CHARACTER 1 (sally)
SECTION
CHARACTER 2 (buys)
BODY SYSTEM
CHARACTER 3 (root)
ROOT OPERATION
CHARACTER 4 (beer)
BODY PART
CHARACTER 5 (at)
APPROACH
CHARACTER 6 (dairy)
DEVICE
CHARACTER 7 (queen)
QUALIFIER