translating icd-10-pcs root operations and...

3/28/2016

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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


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…



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


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


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


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



Transplantation Putting in a living body part from a person/animal


Kidney transplant

Reattachment Putting back a detached body part


Reattach severedfinger

Transfer Moving, to functionfor a similar bodypart


Skin transfer flap

Reposition Moving, to normal or other suitable location


Move undescendedtesticle


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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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



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)



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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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


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


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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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…


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



Inspection Visual/manual exploration


Diagnostic cystoscopy

Map Locating electrical impulses/functionalareas

Brain/cardiacconduction mechanism

Cardiac Electrophysiologicalstudy

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ROOT OPERATIONS INVOLVING EXAMINATION ONLY


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


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


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 3 Root

Operation Character 4 Body Part


Character 6 Device


Medical and Surgical

0

Female Reproductive

System

U

Excision

B

Uterus

9

Via Natural or ArtificialOpening

Endoscopic

8

No Device

Z

No Qualifier

Z


0

Female Reproductive

System

U

Extraction

D

Endometrium

B


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 3 Root Operation

Character 4 Body Part


Character 6 Device



0

Ear, Nose, Sinus

9

Removal

P

TympanicMembrane,

Right

7


Endoscopic

8

DrainageDevice

0

No Qualifier

Z


0

Ear, Nose, Sinus

9

Extirpation

C

TympanicMembrane,

Right

7


Endoscopic

8

No Device

Z

No Qualifier

Z


0

Ear, Nose, Sinus

9

Extraction

D

TympanicMembrane,

Right

7


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


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



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



CASE 2

0 Medical Surgical

U Female Reproductive System

T Resection

Character 4 BodyPart


Character 6 Device


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




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 6Device


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

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