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3/28/2016
1
TRANSLATING ICD-10-PCS ROOT OPERATIONS AND SERVICES
Cynthia Stewart, CPC,
COC, CPMA, CPC-I
OBJECTIVES
•Discuss reasons for standardization of terminology in ICD-10-PCS
•ICD-10-PCS Grouping of operative terms
•Define Root Terms used to create ICD-10-PCS operative services
•Identify Root Terms from documentation snippets
ICD-10-PCS - TERMINOLOGY
Standardized terminology within the coding systemNo eponyms
No common procedure names
Standardized level of specificity Each code represents a single procedure variation
No diagnostic information
No Combination Codes
No explicit “not elsewhere classified” code options
Limited use of “not elsewhere classified” codes
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ICD-10-PCS – STANDARDIZED TERMINOLOGY
Words commonly used in clinical vocabularies may have multiple meanings. Each term used in PCS is defined in PCS
Each root operative term describes a single, precise surgical objective
Example: Excision – Cutting out or off, without replacement, a portion off a portion of a body part.
ICD-10-PCS – STANDARDIZED TERMINOLOGY
Root Operative Term
Bypass
By body system
Peritoneal Cavity 0W1G
Spinal Canal 001U
Common Procedure Term
CholecystectomySee Excision, Gallbladder 0FB4
See Resection, Gallbladder 0FT4
ROOT OPERATIVE TERMS
31 distinct root operations
Identify objective of the procedure
Medical and Surgical root operations divided into groups based upon similar attributes
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ROOT OPERATIONS THAT TAKE OUT SOME OR ALL OF A BODY PART
Root Operation Objective of Procedure
Site of Procedure Example
Excision Cutting out/off without replacement
Some of a body part
Breast lumpectomy
Resection Cutting out/off without replacement
All of a body part Total mastectomy
Detachment Cutting out/off without replacement
Extremity only, anylevel
Amputation above elbow
Destruction Eradicating without replacement
Some/all of a body part
Fulguration of endometrium
Extraction Pulling out or off without replacement
Some/all of a bodypart
Suction D&C
ROOT OPERATIONS THAT TAKE OUT SOME OR ALL OF A BODY PART
Documentation Examples
Using sharp and blunt dissection the cyst was freed from the surrounding tissue and removed intact…
Suction cannula was placed and suction curettage performed with no residual endometrial lining…
ROOT OPERATIONS THAT TAKE OUT SOME OR ALL OF A BODY PART
Documentation Examples
Radiofrequency needle was introduced under fluoroscopic guidance and 90 seconds coagulation treatment was administered to the trigeminal nerve…
After mobilizing and removing the right colon off the field…
A small rongeurs was then used to remove the head of the third metatarsal…
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ROOT OPERATIONS THAT TAKE OUT SOLIDS/FLUIDS/GASES
Root Operation Objective ofProcedure
Site of Procedure Example
Drainage Taking/letting outfluids/gases
Within a body part Incision and drainage
Extirpation Taking/cutting outsolid matter
Within a body part Thrombectomy
Fragmentation Breaking solid matter into pieces
Within a body part Lithotripsy
ROOT OPERATIONS THAT TAKE OUT SOLIDS/FLUIDS/GASES
Documentation Examples
The cephalic vein was found obstructed. A large number of clots were extracted…
Guidewire was inserted, 8 French locking catheter was positioned in right renal pelvis. Immediate flow of urine was evident….
ROOT OPERATIONS INVOLVING CUTTING OR SEPARATION ONLY
Root Operation Objective of Procedure Site of Procedure
Division Cutting into/separating a body part
Within a body part
Release Freeing a body part from constraint
Around a body part
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ROOT OPERATIONS INVOLVING CUTTING OR SEPARATION ONLY
Documentation Examples
Lateral sphincterotomy was done at the 1 o’clock position using the closed approach, dividing only the internal sphincter…
I visualized that the entire median nerve had been freed of compression…
ROOT OPERATIONS THAT PUT IN/PUT BACK OR MOVE SOME/ALL OF A BODY PART
Root Operation Objective of Procedure
Site of Procedure Example
Transplantation Putting in a living body part from a person/animal
Some/all of a bodypart
Kidney transplant
Reattachment Putting back a detached body part
Some/all of a bodypart
Reattach severedfinger
Transfer Moving, to functionfor a similar bodypart
Some/all of a bodypart
Skin transfer flap
Reposition Moving, to normal or other suitable location
Some/all of a bodypart
Move undescendedtesticle
ROOT OPERATIONS THAT PUT IN/PUT BACK OR MOVE SOME/ALL OF A BODY PART
Documentation Examples:
The flaps were advanced to the cheek defect and secured…
Stabilization was then carried out, with 0.062 K-wire brought down through the distal finger, out through the fingertip, and then back into the proximal phalanx. The A2 pulley was restored, re-approximating flexor tendons. Tendons were repaired and anchored to middle phalanx…
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ROOT OPERATIONS THAT PUT IN/PUT BACK OR MOVE SOME/ALL OF A BODY PART
Documentation Examples:
Artery was placed on vessel loop retraction, and kidney was trimmed on the back table and then brought into the field….
Dissection was carried down to the pelvic cavity, where the right testis was located. Testicle was mobilized down through the inguinal canal into the scrotum….
ROOT OPERATIONS THAT ALTER THE DIAMETER/ROUTE OF A TUBULAR BODY PART
Root Operation Objective of Procedure
Site of Procedure Example
Restriction Partially closingorifice/lumen
Tubular body part Gastroesophagealfundoplication
Occlusion Completely closingorifice/lumen
Tubular body part Fallopian tube ligation
Dilation Expandingorifice/lumen
Tubular body part
Percutaneous transluminal coronary angioplasty (PTCA)
Bypass Altering route of passage
Tubular body part Coronary artery bypass graft (CABG)
ROOT OPERATIONS THAT ALTER THE DIAMETER/ROUTE OF A TUBULAR BODY PART
Documentation Examples:
At this point an end-to-side anastomosis was made between the graft and femoral arteries…
The balloon was placed in the left anterior descending artery and inflated times two for five minutes…
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ROOT OPERATIONS THAT ALTER THE DIAMETER/ROUTE OF A TUBULAR BODY PART
Documentation Examples:
A syringe of 500-700 microns biospheres was then instilled slowly through the catheter resulting in cessation of flow through the uterine artery…
Once placement of the endovascular coil was completed, embolization of cerebral aneurysm was achieved…
ROOT OPERATIONS THAT ALWAYS INVOLVE A DEVICERoot Operation Objective of
ProcedureSite of Procedure Example
Insertion Putting in non-biologicaldevice
In/on a body part Central line insertion
Replacement Putting in device that replaces a body part
Some/all of a bodypart
Total hip replacement
Supplement Putting in device that reinforces or augments abody part
In/on a body part Abdominal wall herniorrhaphy using mesh
Change Exchanging device w/outcutting/puncturing
In/on a body part Drainage tube change
Removal Taking out device In/on a body part Central line removal
RevisionCorrecting a malfunctioning/displaceddevice
In/on a body partRevision of a pacemaker insertion
ROOT OPERATIONS THAT ALWAYS INVOLVE A DEVICE
Documentation Examples:
Introducer kit was introduced into subclavian vein and Port-a-cath was placed through the introducer into the superior vena cava…
The rectocele was then imbricated using mattress sutures and the area of the levator ani reinforced with Gynemesh…
Uneventful exchange of tracheostomy tube…
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ROOT OPERATIONS THAT ALWAYS INVOLVE A DEVICE
Documentation Examples:
Underlying tubing was delivered through the suprapubic region. The pump device was then repositioned in the left lower quadrant abdominal wall region…
The external fixator was detached and pulled free using the appropriate wrench. The four pins in the ulna were taken out with the drill…
ROOT OPERATIONS THAT ALWAYS INVOLVE A DEVICE
Documentation Example:
The lens was prolapsed in the anterior chamber and removed. A posterior chamber intraocular lens was inspected, rinsed, and placed into the capsular bag…
ROOT OPERATIONS INVOLVING EXAMINATION ONLY
Root Operation Objective of Procedure
Site of Procedure Example
Inspection Visual/manual exploration
Some/all of a bodypart
Diagnostic cystoscopy
Map Locating electrical impulses/functionalareas
Brain/cardiacconduction mechanism
Cardiac Electrophysiologicalstudy
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ROOT OPERATIONS INVOLVING EXAMINATION ONLY
Documentation Examples:
Colposcopy was done which revealed pseudo-white areas at 12 o’clock on the cervix, with abnormal cells and irregular white borders noted…
Electrical catheter was advanced up the aorta and into left atrium and mapping commenced….
ROOT OPERATIONS THAT DEFINE OTHER REPAIRS
Root Operation Objective of Procedure Site of Procedure
Repair Restoring body part to itsnormal structure
Some/all of a body part
Control Stopping/attempting tostop postproceduralbleed
Anatomical region
ROOT OPERATIONS THAT DEFINE OTHER REPAIRS
Documentation Example:
The hernia sac was then ligated at the internal ring with non-dissolving sutures. The hernia was reduced and the internal oblique fascia was sutured in interrupted stitches to the ilio-pubic fascia…
The previous retroperitoneal site was opened. Oozing and a clot was located and removed. Hemostasis was accomplished by cautery…
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ROOT OPERATIONS THAT DEFINE OTHER OBJECTIVES
Root Operation Objective of Procedure
Site of Procedure
Example
Fusion Rendering joint immobile
Joint Spinal fusion
Alteration
Modifying body partfor cosmetic purposeswithout affecting function
Some/all of abody part
Face lift
Creation Making new structurefor sex change operation
Perineum Artificial vagina/penis
ROOT OPERATIONS THAT DEFINE OTHER OBJECTIVES
Documentation Examples:
Attention was turned to the redundant upper eyelid skin. Ellipse of skin as marked was excised bilaterally…
Using the drill, a trough was incised on the anterior surface of the C2 vertebra, the C2/C3 space was evacuated and cartilage removed. Bone bank patella strut graft was trimmed with a saw and fashioned to fit the C2/C3 interspace and tapped into place.
TIPS FOR ACCURATE SELECTION OF ROOT TERMS
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BODY SYSTEM / BODY PART
Interdependence between body system and body partRespiratory System / Upper lung Lobe, Right
Respiratory System/ Lung, Right
Relationship between many root operations and body partUnderstanding this relationship is key to accurate selection of root operation
Resection vs excision
BODY SYSTEM / BODY PART
Open excision of 4 right axillary lymph nodes
Character 1Section
Character 2Body
System
Character 3Root
Operation
Character 4Body Part
Character 5Approach
Character 6Device
Character 7Qualifier
Medical and
Surgical0
Lymphaticand HemicSystems
7Excision
B
Lymphatic,Right
Axillary5
Open0
No DeviceZ
No
Qualifier
Z
Medicaland
Surgical0
Lymphatic and Hemic
Systems7
ResectionT
Lymphatic,Right
Axillary5
Open0
No DeviceZ
No
Qualifier
Z
INDEXING FOR RESECTION VS EXCISION
Resection
Lymphatic
Axillary
Left 07T6
Right 07T5
Does not break down to individual nodes
If only a portion of a Body Part is removed the Root Term is Excision
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OBJECTIVE OF THE PROCEDUREWhat is the objective?
Gastrectomy with anastomosis of distal portion of esophagus to duodenum, open approach
Character 1 Section
Character 2 Body System
Character 3 Root
Operation Character 4 Body Part
Character 5 Approach
Character 6 Device
Character 7 Qualifier
Medical andSurgical
0
Gastrointestinal System
DBypass
1Esophagus
5Open
0No Device
Z
Duodenum
9
Medical andSurgical
0
GastrointestinalSystem
DResection
TStomach
6Open
0No Device
Z
No Qualifier
0
OBJECTIVE OF PROCEDURE
Objective verses method
Destruction of endometrial adhesions of the left ovary to pelvic wall using heat gun
OBJECTIVE OF THE PROCEDURE
Method of completing the objective
Endoscopic removal of endometrial polyp by forceps
Character 1 Section
Character 2 Body System
Character 3 Root
Operation Character 4 Body Part
Character 5 Approach
Character 6 Device
Character 7 Qualifier
Medical and Surgical
0
Female Reproductive
System
U
Excision
B
Uterus
9
Via Natural or ArtificialOpening
Endoscopic
8
No Device
Z
No Qualifier
Z
Medical and Surgical
0
Female Reproductive
System
U
Extraction
D
Endometrium
B
Via Natural or ArtificialOpening
Endoscopic
8
No Device
Z
No Qualifier
Z
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OBJECTIVE OF THE PROCEDUREWhat is being removed?
Endoscopic removal of foreign body in right ear drum requiring removal of a portion of
the tympanic membrane.
Character 1 Section
Character 2 Body System
Character 3 Root Operation
Character 4 Body Part
Character 5 Approach
Character 6 Device
Character 7 Qualifier
Medical and Surgical
0
Ear, Nose, Sinus
9
Removal
P
TympanicMembrane,
Right
7
Via Natural or ArtificialOpening
Endoscopic
8
DrainageDevice
0
No Qualifier
Z
Medical and Surgical
0
Ear, Nose, Sinus
9
Extirpation
C
TympanicMembrane,
Right
7
Via Natural or ArtificialOpening
Endoscopic
8
No Device
Z
No Qualifier
Z
Medical and Surgical
0
Ear, Nose, Sinus
9
Extraction
D
TympanicMembrane,
Right
7
Via Natural or ArtificialOpening
Endoscopic
8
No Device
Z
No Qualifier
Z
BIOPSIES IN ICD-10-PCS
Identified by Qualifier Character X (7th Character)
Root term is based upon the method sample was removed
Further defined by Body part removed
Biopsy
see Drainage with qualifier Diagnostic
see Excision with qualifier Diagnostic
Bone Marrow see Extraction with qualifier Diagnostic
BIOPSIES IN ICD-10-PCS
Character1 Section
Character2 Body System
Character3 Root
Operation
Character4 Body Part
Character 5Approach
Character6 Device
Character 7 Qualifier
Medicaland
Surgical0
RespiratorySystem
BDrainage
9Lung, Right
KPercutaneous
3No Device
Z
Diagnostic
X
Medicaland
Surgical0
RespiratorySystem
BExcision
BLung, Right
KPercutaneous
3No Device
Z
Diagnostic
X
Medical and
Surgical0
RespiratorySystem
BExtraction
D
Pleura, Right
NPercutaneous
3No Device
Z
Diagnostic
X
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CASE EXAMPLES – IDENTIFY THE ROOT OPERATIVE TERMS
POST-OPERATIVE DIAGNOSIS: Some mild inflammatory changes noted at the GE junction; hiatal hernia
OPERATION: EGD with biopsy using forceps.
SPECIMEN: Biopsy from GE junction
GROSS FINDINGS: No evidence of esophageal strictures or narrowing or varicosities but there was some
inflammation noted at the GE junction on the stomach side. Representative biopsies were performed. Remaining
part of the stomach and duodenum were unremarkable. She had moderated hiatal hernia.
OPERATIVE PROCEDURE: Once the patient was properly identified and consent reviewed, the patient was
brought to the endoscopy suite where the procedure was verified by patient as well as surgeon. Patient was
placed in the supine semi-seated position. Flexible endoscope was passed under direct visualization into the
esophagus. Esophagus was insufflated. Scope was advanced. Esophagus and GE junction were normal
appearing. Right at the GE junction just distal to it on the stomach side, there were inflammatory changes and
area of inflammation. No evidence of active bleeding or ulceration. Representative biopsies were performed of
this locale. Stomach was insufflated. Scope passed through the GE junction into the stomach. Stomach was
insufflated. Scope was retroflexed. Cardia, fundus and antrum remaining parts were unremarkable. Scope was
then advanced through the pylorus to the duodenum and passed duodenal sweep. Duodenum was
unremarkable. Scope was fully retrieved and patient was sent to the recovery room in stable condition.
CASE 1 – ROOT TERMRoot Operation Objective of Procedure
Excision Cutting out/off without replacement
Resection Cutting out/off without replacement
Extraction Pulling out or off without replacement
Removal Taking out a device
Medical and
SurgicalGastrointestinal
System Excision EsophagogastricJunction
Via Natural or
ArtificialOpening
No Device Diagnostic
0 D B 4 7 Z x
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POST-OPERATIVE DIAGNOSIS: Persistent menorrhagia leading to profound anemia; submucous uterine fibroid
OPERATION: Total abdominal hysterectomy
GROSS FINDINGS: Upon entering the peritoneal cavity, an enlarged lobulated approximately 12-week sized uterus was noted. There was evidence of bilateral tubal ligation in the past.
OPERATIVE PROCEDURE: Following administration of general anesthesic, Her abdomen was prep with and draped in the usual manner. Using a scalpel blade, a 7” transverse lower abdominal incision was madeand carried down through the subcutaneous tissue and opening the rectus The overlying fascia was then dissected off the underlying musculature using the Bovie. Rectus muscles were split in the midline, peritoneum elevated, entered, and opened longitudinally. O’Connor-O’Sullivan retractor was placed in the abdomen and the bowel packed away with moist lap sponges. Mass General clamp was placed on the fundus of the uterus and uterus elevated towards the incision. The round ligaments were then bilaterally clamped , cut, doubly suture ligated with #1 chromic, left long, and tagged. The infundibulopelvic ligaments were bilaterally skeletonized a short distance and then were bilaterally clamped, cut and doubly suture litgated with #1 chromic.
At this point, the fundus of the uterus was removed using a scalpel blade. The cervical stump was then grasped and using straight Heaney clamps, the cardinal ligaments were bilaterally clamped, cut, suture ligated. The vagina was entered anteriorly using a scapel blade and utilizing Jorgensen scissors and staying within the vaginal fornices, the cervix was excised off the vaginal cuff.
Pelvis was irrigated and suctioned dry and the pelvic peritoneum reapproximated with a continuous running stitch of 2-0 chromic. Pelvis was reirrigated, bowel replaced into his physiologic position, and tall the pecks and instruments were removed from the abdomen. The abdominal peritoneum was closed. The rectus musculature, rectus fasola were reapproximated with a continous running stitch. Subcutaneous tissue and the skin edge was reapproximated with a series of skin staples followed by a series of vertical mattress sutures of 4-0 Rapide placed between every staple to maintain good skin eversion. Sterile dressing was applied.
CASE 2 – ROOT TERM
Resection
Uterus 0UT9
Root Operation
Objective of Procedure
Excision Cutting out/off without replacement
Resection Cutting out/off without replacement
CASE 2
0 Medical Surgical
U Female Reproductive System
T Resection
Character 4 BodyPart
Character 5 Approach
Character 6 Device
Character 7Qualifier
Uterus9
Open0
No DeviceZ
No Qualifier
Z
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1. Bilateral microscopic tympanotomies with ventilation tube placement, 7 mm vent tubes.
2. Adenotonsillectomy.
PROCEDURE IN DETAIL:
A 2-year-old female taken to the OR, prepped and draped in a sterile manner. General anesthesia applied via endotracheal intubation by the anesthesia department. Operating microscope was brought in surgical field with direct visualization of the right external auditory canal via 3.5 mm ear speculum. All excessive cerumen was removed via loop. The patient had a preexisting PE tube that was lying within the external auditory canal. An incision was then manufactured in the anterior inferior quadrant of tympanic membrane utilizing the tympanostomy knife. The patient had significant mucopurulent debris within the middle car cleft. It was evacuated with #5 Frazier lip suction. A 7-mm vent tube was then placed within the tympanic membrane without difficulty complications. Cortisporin drops along with the sterile cotton ball were applied. A similar procedure was performed in the contralateral side without difficulty, complicatons.
Patient rotated to 90 degrees, the Mclvor oral retractor was then placed within the oral cavity suspended via the Mayo stand. Initially, the uvula was retracted superiorly, which revealed mild to moderate obstructive adenoidal hypertrophy. Adenoidectomy was then performed utilizing a small size curette. Approximately 1 tonsillar sponge was then placed within the posterior nasopharynx and left there for proximately 5 minutes. During this lime, the tonsils were tentative. Upon physical examination, tonsils were +3 to 4 with definitely occluding the oropharyngeal airspace. Initially, the right tonsil was then grasped at the superior pole of the curved Allis and using electrocautery the right tonsil was dissected down access of the inferior pole. Hemostasis was easily obtained using suction cautery. Following this the left tonsil was then grasped with the superior pole of the curved Allis and again using electrocautery, the left tonsil was dissected down excess of the inferior pole. Hemostasis was easily obtained using suction cautery. The tonsillar sponge was removed from the posterior nasopharynx. The oral cavity and nasopharynx were irrigated with copious amounts of normal saline, which revealed no active hemorrhage or gross complications. The patient was sent to the recovery room
CASE 3 ROOT TERMS1) Adenotonsillectomy
2) Tympanotomies with ventilation tube placement
Root Operation Objective of Procedure
Excision Cutting out/off without replacement
Resection Cutting out/off without replacement
Division Cutting into/separating a body part
Insertion Putting in a non-biological device
Drainage Taking or letting out fluids or gasses
CASE 3Character 1
Section
Character 2Body
System
Character 3 Root
Operation
Character 4Body Part
Character 5 Approach
Character 6Device
Character 7Qualifier
Medical andSurgical
0
Ear, Nose, Sinus
9Drainage
9
TympanicMembrane,
Right 7
Via Naturalor ArtificialOpening
7
Drainage Device
0
No Qualifier
Z
Medical andSurgical
0
Ear, Nose, Sinus
9Drainage
9
TympanicMembrane,
Left 8
Via Naturalor Artificial Opening
7
Drainage Device
0
No Qualifier
Z
Medical andSurgical
0
Mouth andThroat
CResection
TTonsils
PExternal
XNo Device
Z
No Qualifier
Z
Medical andSurgical
0
Mouth and Throat
CResection
TAdenoids
QExternal
XNo Device
Z
No Qualifier
Z
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QUESTIONS
CEU CODE