Introducing ICD-10-PCS Root Operation Group 7

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Introducing ICD-10-PCS Root Operation Group 7

• Presented by
• Kathy L. Hallock, RHIA, CDIP,
• AHIMA I 10 Certified Trainer

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Lets Review

• Root Operation Overview
• Root Operation --- 6

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ICD-10-PCS Characters
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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

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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.

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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

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Your Turn to Practice
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Lets review Group 6

• Procedures that always involve
• devices

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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.

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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

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Chest tube replacement
Change
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Relocation of pacemaker pocket
Revision
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Cystoscopy with retrieval of right ureteral stent
Removal
Image mayoclinic.org
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Open anterior colporrhaphy with polypropylene
mesh reinforcement
Supplement
Image urogyn-nj.com
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Percutaneous placement of bone growth stimulator
electrode, left femoral shaft
Insertion
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Right mastectomy with free TRAM flap
reconstruction
Replacement
Image breastcancer.org
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Group 7 Root Operations Involving Examination
Only
Inspection
Map
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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

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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.

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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.

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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.

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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

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Coding Note Procedures that are discontinued
without any other root operation being performed
are coded to inspection.
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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)

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• 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).

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My wheels are turning, I think Im getting
it!!!!!!!
ICD 10 makes no sense?????
Your brain on I-10
Your brain on I-9