MEMORANDUM To:
New Coders
From:
Coding Supervisor
Date:
March 7, 2018
Subject:
Root Operation/Medical and Surgical Guidelines
Good Morning New Coders,
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With all the new coders I thought it would be best to give some initial insight on the ICD-10-PCS Coding Guidelines. I would like to discuss two of the Root Operation guidelines found under the Medical and Surgical guidelines section in the front of the code book. I would like to start with the common principle “Coding with Integrity”. The demand for trustworthy data has never been more apparent than it is today, and the coding process plays a critical role in meeting the need for complete, accurate, and reliable healthcare data. Therefore reading, understanding and using the guidelines in your coding book is very important. I would like to outline two of the root operations to help you understand how these guideline work and what they mean and how to code using the guidelines. Here are some examples of procedures, their definitions, instructions, and the guidelines to help you with ICD-10-PCS codes. Starting with the root operation guidelines for biopsy procedures under the medical and surgical section: Biopsy procedures B3.4a Biopsy procedures are coded using the root operations Excision, Extraction, or Drainage and the qualifier Diagnostic. Examples: Fine needle aspiration biopsy of fluid in the lung is coded to the root operation Drainage with the qualifier Diagnostic. Biopsy of bone marrow is coded to the root operation Extraction with the qualifier Diagnostic.
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Lymph node sampling for biopsy is coded to the root operation Excision with the qualifier Diagnostic.
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What this means is, a Fine-needle aspiration biopsy is reported with the root operative term “Drainage” (taking or letting out fluids and/or gases from a body part). This is actually more specific and accurate, as the physician uses a thin needle to draw out-or-drain-some fluid or gas to be used for testing. For example, an amniocentesis would be reported with ICD-10-PCS code 10903ZU (Drainage of amniotic fluid, diagnostic from products of conception, percutaneous approach). Each of the characters making up the code would be: 1 Obstetrics 0 Pregnancy
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9 Drainage 0 Products of conception 3 Percutaneous approach Z No device U Amniotic fluid, Diagnostic Next, we have the second part to Biopsy which is: Biopsy followed by more definitive treatment B3.4b If a diagnostic Excision, Extraction, or Drainage procedure (biopsy) is followed by a more definitive procedure, such as Destruction, Excision or Resection at the same procedure site, both the biopsy and the more definitive treatment are coded.
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Example: Biopsy of breast followed by partial mastectomy at the same procedure site, both the biopsy and the partial mastectomy procedure are coded.
This means that at times the biopsy may be done and analyzed and directly followed by a more extensive procedure during the same encounter or session. B3.4b says that the procedures should be reported separately. For example a physician performs a lumpectomy of the right breast followed by mastectomy during the same session. Coders should report codes 0HBT3ZX (Excision of right breast, percutaneous approach, diagnostic) and 0HTT0ZZ (Resection of right breast, open approach). The individual characters for these respective codes are: 0, Medical and Surgical H, Skin and Breast B, Excision T, Breast, Right 3, Percutaneous Z, No device X, Diagnostic
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0 Medical and Surgical H Skin and breast T Resection Cutting out or off, without replacement, all of a body part T Breast, right 0 Open Z No device Z No Qualifier
Now, let’s look at another example, Control vs. more definitive root operations: Control vs. more definitive root operations B3.7 The root operation Control is defined as, “Stopping, or attempting to stop, postprocedural or other acute bleeding.” If an attempt to stop postprocedural or other acute bleeding is initially unsuccessful, and to
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stop the bleeding requires performing a more definitive root operation, such as Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then the more definitive root operation is coded instead of Control. Example: Resection of spleen to stop bleeding is coded to Resection instead of Control. What this means is control codes report procedures where the only objective is to stop hemorrhaging that occurs following a procedure. Action taken to control post-procedural hemorrhaging may include irrigating or evacuating a hematoma at the operative site, both of which may be necessary to clear the field and stop the bleeding. Control codes represent only a small range of possible actions performed in the attempt to stop post-procedural bleeding.
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The repair root operation represents procedures with the very broad purpose of restoring a body organ or part to its anatomic structure. Repair is a sort of ‘not elsewhere classified’ root operation of the Medical and Surgical Section of ICD-10-PCS. Although the purpose of a repair root operation appears to be generalized, the use of this root operation is quite limited. Repair may only be used when the procedure performed does not meet the definition of any of the other root operations in the Medical and Surgical Section. The main types of procedures done for this purpose and reported using a repair code are suture (or closure) of lacerations and herniorrhaphies. So, if the physician is unable to stop the bleeding and must perform a more involved procedure, report the root operation for the more significant procedure. In the case of the spleen removal, coders would report 07TP0ZZ (resection of spleen, open approach) or 07TP4ZZ (resection of spleen, percutaneous endoscopic approach). 0 Medical and Surgical 7 Lymphatic and Hemic Systems T Resection Cutting out or off, without replacement, all of a body part P Spleen 0 Open or 4 Percutaneous Endoscopic (The difference is the approach whether it is open or scoped) Z No Device Z No Qualifier
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It is important for you as a new coder to understand why guidelines are important. Guidelines provide consistent data, and it is important for everyone to follow the same coding rules and conventions when assigning codes. Adherence to applicable coding guidelines, conventions, and instructions is absolutely necessary. The official guidelines are additional instructions that must be used to code correctly. They allow the coder to achieve accurate coding and correctly interpret and report medical services. These guidelines are essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. The importance of consistent, complete documentation in the medical record cannot be overemphasized. As we go through the other aspects of code building we will be introducing the “encoder device” which will help all coders in producing an accurate code. The encoder is a device that converts information from one format or code to another, for the purposes of standardization, speed or compressions. With new diseases and procedures to learn each year, continuously changing regulatory requirements to comply with, any coder is likely to welcome this technology that promises to leave their jobs a little less complicated. You will notice that the encoder technology can transcribe clinician notes, extract the key
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