The Complexity of Root Operations in ICD-10-PCS
Inpatient coders are faced with the daunting task of determining the “intent of procedure” when compliantly coding inpatient procedures.
With the inception of the 2017 updates, which became effective October 1, 2016, we are again faced with the lingering questions of the “intent of the procedure” when applying PCS codes. As we continue to see revisions to the PCS coding system, it is important to review Root Operations to remain compliant when coding procedures.
We will look into the coding guidelines and provide some examples of PCS coding in this article. It is always a benefit to start with the past, and move forward. We will start with coding guidelines.
According to 2017 ICD-10-PCS Official Guidelines for Reporting, Guideline A11, “the coder is responsible for selecting the root operation that most closely matches the intent of the procedure.”
The interpretation of this guideline is the coder is not to rely on the term the physician documents to arrive at the correct PCS code for the procedure performed. With the inception of ICD-10-PCS coding, we are reminded that the documentation of procedures from the physician may not always be the actual intent of the procedure.
For example, the physician documents excision of the inner/outer quadrant of the left breasts; however, she takes the entire left breast during the procedure. As the definition of Excision states, “Cutting out or off, without replacement, a portion of a body part;” this Root operation would be incorrect. The physician actually performed a Resection, “Cutting out or off, without replacement, all of a body part.” Taking this into account, coders need to know all nine root groups of operations to correctly identify the correct PCS table and compliantly code the procedure.
Let’s look at the updated PCS definitions released for 2017 from the Centers for Medicare and Medicaid Services.
Control underwent a complete definition revision for the 2017 update. The definition now states, Stopping or attempting to stop post-procedural or other acute bleeding.” The revision added the terms Other Acute Bleeding to the main definition. CMS also emphasizes the prudence of if a more definitive procedure is needed to control the bleeding (i.e., Bypass, Detachment, Excision, Extraction, Reposition, Replacement, and/or Resection), the root operation is coded instead of the root operation Control.
Prior to the 2017 update release, Creation was defined as “making a new genital structure that does not physically take the place of a body part.” The new definition revision now states, “Putting in or on a biological or synthetic material to form a new body part.” This clears up a long-time issue for coders as there was not a logical operation when the Creation would be considered. This also changed the focus of Creation to additional body systems where prior, Creation was only used for sex-change procedures.
Examples of Procedure Coding within PCS:
|Root Operation||Definition||PCS Code Example|
|Alteration||Alteration of Bilateral Breast with synthetic substitute, open approach
|Bypass||Bypass 4+ coronary arteries from coronary artery with autologous venous tissue, open approach||0213093|
|Change||Change tracheostomy device in trachea, external approach
|Control||Control of post-tonsillectomy hemorrhage||0W33XZZ|
|Creation||Creation of Mitral valve from common atrioventricular valve using Zooplastic tissue, open approach||024G082|
|Destruction||Destruction of back skin, multiple, external approach||0H56XZD|
|Detachment||Detachment at right lower leg, high, open approach||0Y6H0Z1|
|Dilation||Dilation of left common carotid artery, bifurcatioin, with three drug-eluting intraluminal devices, open approach||037J066|
|Division||Division of left upper femur, percutaneous approach||0Q873ZZ|
|Drainage||Drainage of right inguinal region with drainage device, percutaneous approach||0Y9530Z|
|Excision||Excision of cerebral meninges, open approach||00B10ZZ|
|Extirpation||Extirpation of matter from coronary artery, two arteries using orbital artherectomy technology, percutaneous approach, new technology group 1||X2C1361|
|Extraction||Extraction of right lens (eye), percutaneous approach||0BDJ3ZZ|
|Fragmentation||Fragmentation in right ureter, via natural or artificial opening, endoscopic||0TF68ZZ|
|Fusion||Fusion of right hip joint with internal fixation device, percutaneous endoscopic approach||0SG944Z|
|Insertion||Insertion of endotracheal airway into trachea, via natural or artificial opening||0BH17EZ|
|Inspection||Inspection of lower intestinal tract, via natural or artificial opening endoscopic (Diagnostic Colonoscopy)||0DJD8ZZ|
|Map||Map conduction mechanism, percutaneous approach||02K83ZZ|
|Occlusion||Occlusion of bilateral fallopian tubes with intraluminal device, percutaneous endoscopic approach||0UL74DZ|
|Reattachment||Reattachment of left lower arm and wrist tendon, percutaneous endoscopic approach||0LM64ZZ|
|Release||Release right hand tendon, open approach (Trigger Finger Release)||0LN70ZZ|
|Removal||Removal of drainage device from right upper extremity, percutaneous endoscopic approach||0XP640Z|
|Repair||Repair right lower leg tendon, open approach||0LQN0ZZ|
|Replacement||Replacement of right knee joint with synthetic substitute, cemented, open approach||0SRC0J9|
|Reposition||Reposition right carpal, percutaneous approach||0PSM3ZZ|
|Resection||Resection of descending colon, percutaneous endoscopic approach||0DTM4ZZ|
|Restriction||Restriction of lower femoral vein, open approach||06VN0ZZ|
To remain compliant when coding PCS procedures, we must always have the correct intent of procedures at hand. We should also ensure to correctly follow Coding and Reporting Guidelines inherently. It is also important that the documentation lead the coder to the correct PCS code based on the intent of the procedure. If the documentation is not clear, query!