Introducing ICD-10-PCS Root Operation Group 7 Presented by: Kathy L. Hallock, RHIA, CDIP, AHIMA I 10 Certified Trainer
Let’s Review Root Operation – Overview Root Operation --- 6
ICD-10-PCS Characters 1 2 3 4 5 6 7 Root Operation Qualifier Section Approach Body System Body Part Device
Root operations • Objective of the procedure • Third character in the procedure code • ICD-10-PCS: Appendix B • 31 root operations • 9 Groups that share similar attributes
31 MEDICAL AND SURGICAL ROOT OPERATIONS • There is a specific definition for each of these roots. • The full definition of the root operation must be applied • ICD-10-PCS uses terminology that coders are not accustomed to seeing on a daily basis in records. • The purposes of this training is to help the coder smoothly transition to the new root operations and their meanings.
31 ROOTS – 9 GROUPS • Take out some or all of a body part • Take out solids/ fluids/gases from a body part • Involve cutting or separation only • Put in/put back or move some or all of a body part • Alter the diameter or route of a tubular body part • Always involve a device • Involve examination only • Involve other repairs • Involve other objectives
Let’s review— Group 6 Procedures that always involve devices
Group 6 - Definitions • Insertion – Putting in a non-biological appliance that monitors, assists, performs or prevents a physiological function but does not physically take the place of 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. • Supplement- Putting in or on biologic or synthetic material that physically reinforces and/or augments the function of a portion of a body part.
Group 6 - Definitions Change – Taking out or off a device from a body part and putting back an or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane Removal – Taking out or off a device from a body part. Revision – Correcting, to the extent possible, a malfunctioning or displaced device
Chest tube replacement Change
Relocation of pacemaker pocket Revision
Cystoscopy with retrieval of right ureteral stent Removal Image: mayoclinic.org
Open anterior colporrhaphy with polypropylene mesh reinforcement Supplement Image: urogyn-nj.com
Percutaneous placement of bone growth stimulator electrode, left femoral shaft Insertion
Right mastectomy with free TRAM flap reconstruction Replacement Image: breastcancer.org
Inspection – (J) Visually and/or manually exploring a body part. • Visual exploration may be performed with or without optical instrumentation. Manual exploration maybe performed directly or through intervening body layers • Example: Diagnostic bronchoscopy of the left upper lobe
Coding Guideline B3.11a Inspection of a body part(s) integral to the performance of the procedure is not coded separately. Example: Fiberoptic bronchoscopy with irrigation of bronchus, only the irrigation procedure is coded.
Coding Guideline B3.11b • Inspection of Multiple Parts: • If multiple non-tubular body parts are inspected, body part character is defined as the general body part value that identifies the entire area inspected. • If multiple tubular parts are inspected, the body part character is defined as the most distal body part inspected. Example: Cystourethroscopy with inspection of the bladder and ureters is coded to the ureter body part value. Exploratory laparotomy with general inspection of abdominal contents is coded to the Peritoneal Cavity body part value.
Coding Guideline B3.11c • Inspection with another Procedure • 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. • Example – Percutaneous endoscopic inspection of the small intestine during a procedure in which open excision of the duodenum is performed.
Coding Guideline B4.8 Gastrointestinal Body System General body part values Upper Intestinal and Lower Intestinal Tract are provided as an option for Change, Inspection, Removal and Revision Upper Intestinal Tract includes from the esophagus down to and including duodenum Lower Intestinal Tract includes from the jejunum down to and including the rectum and anus
Coding Note: Procedures that are discontinued without any other root operation being performed are coded to inspection.
Map – (K) Locating the route of passage of electrical impulses and/or locating functional areas in a body part Examples: Cardiac mapping, cortical mapping, cardiac electrophysiological study (EPS)
Mapping procedures include only cardiac mapping and cortical mapping. Coding Note: The only 2 Body Systems under Map are the Central Nervous System (00K) and Heart and Great Vessels (02K).
My wheels are turning, I think I’m getting it!!!!!!! ICD 10 makes no sense????? Your brain on I-10 Your brain on I-9