The 31 root operations in the Medical and Surgical section of the ICD-10-PCS Manual can be divided into nine different categories, one of which is root operations that take out some or all of a body part.
Five different root operations fall into this category, but--to an extent—they are simple to differentiate. For example, coders will only use root operation Detachment (third character 6) when the physician cuts off all or some of an upper or lower extremity. Meanwhile, Extraction (D) involves pulling or stripping out or off all or a portion of a body part by the use of force. And Destruction (5) is the physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent.
The remaining two root operations, Excision and Resection, are sometimes harder to distinguish. ICD-10-PCS defines Excision (B) as cutting out or off, without replacement, a portion of a body part. Resection (T) is almost identical, but involves cutting out or off the entire body part.
"Excision and Resection are two that we've seen being the most problematic for coders to decide which one to use," says Nena Scott, MSEd, RHIA, CCS, CCS-P, AHIMA-approved ICD-10-CM/PCS trainer, director of education at TrustHCS in Springfield, Mo.
Root operations guidelines
ICD-10-PCS puts the burden of choosing the correct root operation squarely on the shoulders of coders. ICD-10-PCS guideline A.11 states:
Many of the terms used to construct PCS codes are defined within the system. It is the coder's responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear.
Example: When the physician documents "partial resection" the coder can independently correlate "partial resection" to the root operation Excision without querying the physician for clarification.
That means coders must know not only the definitions of the root operations but also the intent of the procedure.
Coding in ICD-10-PCS is all about the operative report and the table, says Scott. The coder must represent the information in the operative report and can only use one row of the table. Each component of the code must be represented in the operative report.
In order to determine the appropriate root operation, coders must apply the full definition of the root operation as contained in the ICD-10-PCS tables.
"The components of a procedure specified in a root operation definition and explanation are not coded separately," Scott says. "Procedural steps to reach the operative site and close the operative site are also not coded separately."
For example, resection of a joint as part of a joint replacement procedure is included in the definition of the root operation replacement and is not coded separately, Scott says. Similarly, in a resection of sigmoid colon with anastomosis of descending colon to rectum, the anastomosis is not coded separately.
Body part values
Coders can't build an ICD-10-PCS code by looking at root operations in a vacuum. They also need to consider the body part values (fourth character). Each ICD-10-PCS table includes its own list of body parts based on the body system (second character) and the root operation.
Some body part values are very specific, while others are more general or include several different areas. For example, ICD-10-PCS table 0KT (resection of muscles) includes more general body parts, such as:
- Q, upper leg muscle, right
- R, upper leg muscle, left
Both the sartorius muscle and the gracilis muscle are classified as upper leg muscles. So if a physician performs a resection of both the right sartorius muscle and the right gracilis muscle, coders will need to report the code twice, Scott says.
CDI specialists and other concurrent reviewers need to examine the operative report very carefully to see if the physician performed multiple procedures involving the same body part, says Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, director of auditing and CDI services for TrustHCS.
If the physician performs two different procedures on the same body part, for example destruction of a sigmoid lesion and bypass of a sigmoid colon, coders will report two different codes—one for the destruction and one for the bypass. Both fall under the same body part, but involve procedures with different objectives and thus different root operations.
Coders and CDI specialists will also need to determine whether multiple body sites are incorporated into the same ICD-10-PCS body part value, Dominesey says.
Sometimes surgeons don't always list everything in the procedure they say they performed, Scott adds. "You have to read the body of the report and make sure that if there's other things being done on other body parts that we are coding everything appropriately."
- C, upper lung lobe, right
- D, middle lung lobe, right
- F, lower lung lobe, right
- G, upper lung lobe, left
- H, lung lingula (a projection of the upper lobe of the left lung that serves as the homologue)
- J, lower lung lobe, left
Coders will need to carefully review the operative report to determine how much of the body part the physician removed and then determine if ICD-10-PCS includes a separate body part value for that portion.
ICD-10-PCS guideline B3.8 states:
ICD-10-PCS contains specific body parts for anatomical subdivisions of a body part, such as lobes of the lungs or liver and regions of the intestine. Resection of the specific body part is coded whenever all the body part is cut out or off, rather than coding Excision of a less specific body part.
Analyze the documentation
When deciding which root operation to code, as with any coding process, analyzing the documentation should come first. The operative report should describe the "intent" of the procedure and the surgical technique. This review of documentation will support selection of the root operation.
"When you look at Excision versus Resection, it's important to remember that coding is all about that operative report and what it's telling us," Scott says. Coders need to remember that the table drives the code, and the body part is based on the table they are using. "When you look for a code and you've got to determine if it's an Excision or a Resection, you've got to go to that table and determine, did they take out all of that body part or did they take out a piece of that body part?"
When looking at an operative report and trying to determine whether the physician performed an Excision or a Resection, coders should look at both of the tables, Scott says. They should examine what body parts are listed and then think about what the physician actually did in that particular procedure.
For example, a left upper lung lobectomy is coded to a Resection of the upper lung lobe rather than an Excision of the left lung because the table includes the more specific body part, Scott says.
Clinicians also need to understand that what they consider a body part based on anatomy does not always sync up with body part values as designated under ICD-10-PCS. "While there may be a more specific body part that we know from anatomy, when we code this or when we are querying, we need to recognize what the PCS table is telling us," Dominesey says.
Go back to the example of the sartorius and the gracilis muscles. Both are incorporated into a less specific body part value of the upper leg muscles, Dominesey says. "ICD-10-PCS has built in some places for us to request to have those body parts expanded," he says.
In the lobectomy case, ICD-10-PCS provides a body part value for each of the lobes of the lung—three on one side and two on the other. So taking out an entire lobe will be a Resection versus an Excision of just part of the left lung, Dominesey says. "Clinicians have to just recognize that as one of the limitations that we have in PCS. We have a great system, but it's not going to be perfect."
"There are going to be other things that we may be able to pick up on in that operative report to make sure that we're coding it to the degree that we can code it," Scott says.
CDI specialists will also need to carefully read the operative reports, Dominesey says. Coders can no longer stop when they arrive at a surgical DRG. CDI specialists need to help make the documentation as strong as possible so when it does get to the coder, he or she can apply the correct number of codes and not have to hold up that chart and increase the Discharged Not Final Billed days.
Operative note excerpt
Consider the following partial operative report documentation:
The colon was mobilized to the left end up to the level of the hepatic flexure. The mesentery was incised sharply with a knife and down to the level of the root of the mesentery. The mesentery of the right colon and the distal ileum was then taken down between Kellys and tied with #2-0 silk, down to the level of the takeoff vessels.
After removing the right colon specimen of the field, a primary anastomosis was planned …
The operative report indicates that the surgeon used an open approach.
The next step is to apply the definitions of the root operations. The excerpt shows that the physician performed a Resection. By looking up Resection, intestine, in the ICD-10-PCS alphabetic index, coders know to go to table 0DT.
"When you get those three to four characters in the alphabetic index, and usually it's four, you're going to go to the appropriate table," Scott says. The tables are in numeric and alphabetic order. "Once you find that table, then you've got to build the code." Coders should take care to stay on the appropriate line and column of the table.
This particular procedure involves the gastrointestinal system, which provides the second character D. "When you go to a table and you see the codes, maybe you ended up in a respiratory system and you know this was a colon procedure," Scott says. "That's a good way to say, 'Oh, I'm in the wrong table, so let me go back and look at that again.' "
Coders should think about whether the physician really performed a Resection—cutting out or off all of a body part—instead of performing an Excision. In this case, the physician did perform a Resection of the right large intestine (fourth character F).
The next character is the approach. ICD-10-PCS includes seven approach characters, but not every table will include all of these characters, Scott says. Some procedures can only be performed using certain approaches. The seven approaches in ICD-10-PCS are:
- 0, open
- 3, percutaneous
- 4, percutaneous endoscopic
- 7, via natural or artificial opening
- 8, via natural or artificial opening endoscopic
- F, via natural or artificial opening with percutaneous endoscopic assistance
- X, external
In this example, the approach is open.
For the final two characters, table 0DT does not include any device options other than Z (no device), and the only qualifier option is also Z (no qualifier), making the final code 0DTF0ZZ.
Biopsies
Coders will also use the root operation Excision when the physician performs a biopsy of an organ. Coders should be able to tell from the operative report whether the physician biopsied a tissue sample or a fluid, Dominesey says. When physicians sample tissue, coders will report an Excision because that is the root operation that best represents the intent of the procedure.
Coders also need to know that when a physician performs a biopsy, the seventh character—the qualifier—would be X for diagnostic, says Scott.
In some cases, a physician may perform a biopsy and an additional procedure in the same body system. For example, the physician may perform a Destruction of a sigmoid lesion in addition to a biopsy of the sigmoid colon. Those procedures would be coded separately, says Scott, because the intent of each procedure is different.
Coders also need to pay attention to the specific biopsy site. ICD-10-PCS includes three separate body part values for the liver:
- Liver, 0
- Right lobe, 1
- Left lobe, 2
If the physician performed a fine needle aspiration biopsy of the left lobe of the liver, coders would report 0FB23ZX (excision of right lobe liver, percutaneous approach, diagnostic). If the physician uses an open approach but does not specify which lobe was biopsied, coders would report 0FB00ZX (excision of liver, open approach, diagnostic).
Editor’s note: This article was originally published in the March issue of Briefings on Coding Compliance Strategies.Email your questions to Senior Managing Editor Michelle A. Leppert, CPC, at mleppert@hcpro.com.