Coding Root Operations with ICD-10-PCS: Understanding Detachment, Destruction, and Extraction

By Ann Barta, MSA, RHIA

Editor's note: This is the second in a series of 10 articles discussing the 31 root operations of ICD-10-PCS.

One of the keys to understanding ICD-10-PCS is the many new definitions and descriptions used to describe the various components of performed procedures. The root operation-the third character of an ICD-10-PCS code-describes the objective or main focus of the procedure. The Medical and Surgical section of ICD-10-PCS contains 31 root operations. Each of these root operations has a very well-defined meaning. Coding professionals should begin preparing now by gaining an understanding of the definitions and explanations of the various root operations.

This article will focus on the definitions of three root operations:

• Detachment
• Destruction
• Extraction

Detachment: Root Operation 6

The definition for the Detachment root operation provided in the 2013 ICD-10-PCS Reference Manual is "Cutting off all or part of the upper or lower extremities." The body part value is the site of the detachment, with a qualifier where applicable to further specify the level where the extremity was detached. The specific qualifiers assigned are dependent on the body part value in either the upper or lower extremity body systems. The definitions for the qualifiers are located in the ICD-10-PCS Reference Manual.

Some examples of Detachment procedures are fifth toe ray amputation, right above-knee amputation of distal femur, and left fourth toe amputation at mid-proximal phalanx.

Comparing ICD-9-CM and ICD-10-PCS: Detachment

The following is an example of how ICD-9-CM and ICD-10-PCS compare when determining a code assignment for Detachment procedures.

Scenario

A procedure of an amputation extended to the midshaft of the left fifth metatarsal was performed. The procedure was performed by first making a semi-elliptical incision around the base of the left toe and then removing the head of the fifth metatarsal extending the amputation to the midshaft of the fifth metatarsal.

Coding in ICD-9-CM

In ICD-9-CM, the Alphabetic Index entry main term Amputation, subterm midtarsal identifies code 84.12, Amputation through foot. This code is assigned for amputations of forefoot, amputation through middle of foot, midtarsal amputation, and transmetatarsal amputation of either the right or left foot.

Coding in ICD-10-PCS

In ICD-10-PCS, the root operation for this procedure is Detachment since the main objective is to cut off part of the lower extremity. The Alphabetic Index entry main term Amputation refers the coding professional to see Detachment.

A review of the subterms located under the main term Detachment indicates that the correct table to build the code for this procedure is Table 0Y6. The ICD-10-PCS code for this procedure is 0Y6N0ZF. The fourth character (N) identifies the body part as the left foot and the seventh character (F) identifies the level of detachment as partial fifth ray. The definition for partial fifth ray is amputation anywhere along the shaft or head of the fifth metatarsal bone of the foot. The fifth character identifies the technique to reach the operative site or approach. The procedural approach was open (0) because an incision was made to reach the operative site.

Destruction: Root Operation 5

The definition for the root operation Destruction provided in the 2013 ICD-10-PCS Reference Manual is "Physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent." None of the body part is physically taken out. Destruction "takes out" a body part in the sense that it obliterates the body part so it is no longer there.

Common procedural terms that meet the definition of Destruction in ICD-10-PCS include:

• Ablation
• Cautery
• Coagulation
• Cryotherapy
• Destruction
• Fulguration
• Pleurodesis
• Sclerotherapy

Examples of Destruction procedures include radiofrequency coagulation of trigeminal nerve, fulguration of endometrium, and sclerotherapy of brachial plexus lesion with alcohol injection.

Comparing ICD-9-CM and ICD-10-PCS: Destruction

The following is an example of how ICD-9-CM and ICD-10-PCS compare in code assignment for Destruction procedures.

Scenario

A Therma-Choice balloon endometrial ablation procedure was performed. During this procedure the Therma-Choice catheter with balloon was placed inside the endometrial cavity and slowly filled with fluid until it stabilized at a pressure of approximately 175 to 180 mmHg. Eight minutes of therapeutic heat was applied to the lining of the endometrium.

Coding in ICD-9-CM

In ICD-9-CM, the Alphabetic Index entry main term Ablation, subterm endometrium identifies code 68.23, Endometrial ablation. Code 68.23 would be assigned whether or not a scope was utilized during the procedure.

Coding in ICD-10-PCS

The objective of this procedure is the physical eradication of a portion of the endometrium, therefore Destruction is the appropriate root operation in ICD-10-PCS. The Alphabetic Index entry main term Ablation refers the coding professional to see Destruction.

A review of the subterms located under the main term Destruction indicates that the correct table to build the code for this procedure is Table 0U5. The ICD-10-PCS code for this procedure is 0U5B7ZZ. The fourth character (B) identifies that the procedure was performed on the endometrium and the fifth character (7) identifies the approach is via a natural opening. If the procedure had been performed with the utilization of a hysteroscope then the approach would be via natural opening endoscopic (8).

Extraction: Root Operation D

The definition for the root operation Extraction provided in the ICD-10-PCS Reference Manual is "Pulling or stripping out or off all or a portion of a body part by the use of force." Extraction is coded when the method employed to take out the body part is pulling or stripping, and any minor cutting-such as that used in vein stripping procedures-is included in the Extraction.

Similar to the root operation Excision, to help distinguish biopsies done in the Extraction category, the seventh character qualifier diagnostic (X) has been established. For example, the code for an endometrial biopsy without the use of a scope is 0UDB7ZX. The characters are defined as follows:

• 0 – Medical and Surgical (section)
• U – Female Reproductive System (body system)
• D – Extraction (root operation)
• B – Endometrium (body part)
• 7 – Via Natural or Artificial Opening (approach)
• Z – No Device (device)
• X – Diagnostic (qualifier)

Other examples of Extraction procedures include non-excisional debridement of left foot skin ulcer, bone marrow biopsy, and dilation and curettage.

Comparing ICD-9-CM and ICD-10-PCS: Extraction

The following is an example of how ICD-9-CM and ICD-10-PCS compare in code assignment for Extraction procedures.

Scenario 1

A bone marrow biopsy procedure was performed. During this procedure an 11-gauge Jamshidi biopsy needle was used to obtain a bone marrow biopsy sample from the right posterior iliac crest.

Coding in ICD-9-CM

In ICD-9-CM, the Alphabetic Index entry main term Biopsy, subterms, bone, marrow identifies code 41.31, Biopsy of bone marrow. Code 41.31 does not distinguish either the approach to the procedure or the specific body part.

Coding in ICD-10-PCS

In ICD-10-PCS the root operation for this procedure is Extraction since the main objective is to pull out a portion of the bone marrow.

Due to the larger caliber of the bone marrow biopsy needle, force is required. The Alphabetic Index entry main term Extraction, subterm Bone Marrow refers the coding professional to Table 07D. The ICD-10-PCS code for this procedure is 07DR3ZX. The fourth character (R) identifies the body part as bone marrow, iliac. Unlike ICD-9-CM, the code specifies the specific location of the bone marrow biopsy.

The following fourth character values are provided in Table 07D:

• Q, Bone Marrow, Sternum
• R, Bone Marrow, Iliac
• S, Bone Marrow, Vertebra

The fifth character of the code identifies the technique used to reach the operative site. The approach for the bone marrow biopsy was percutaneous (3). In ICD-10-PCS the fifth character always identifies the specific approach utilized to reach the operative site.

The following is another example of how ICD-9-CM and ICD-10-PCS compare in code assignment for Extraction procedures.

Scenario 2

A suction dilation and curettage (D&C) procedure is performed. During the procedure successive dilators were placed until the cervix was adequate for insertion of the suction cannula. Suction cannula was placed and suction curettage performed with no residual endometrial lining.

Coding in ICD-9-CM

In ICD-9-CM, the Alphabetic Index entry main term Dilation and curettage, uterus identifies code 69.09, Other dilation and curettage. If the D&C had been performed after either a delivery or an abortion, then the code is 69.02, and if performed to terminate a pregnancy, the code is 69.01.

Coding in ICD-10-PCS

Extraction is the correct ICD-10-PCS root operation because during the curettage-defined as scraping-a uterine curette is inserted and the uterine wall scraped. The Alphabetic Index entry main term Extraction, subterm Endometrium refers the coding professional to Table 0UD. The ICD-10-PCS code for this procedure is 0UDB7ZZ.

The fourth character (B) identifies the body part as the endometrium and the fifth character (7) identifies the approach as via natural opening.

Review of ICD-10-PCS coding guideline C2 indicates that a code from the Obstetrics section of ICD-10-PCS would be assigned if this procedure had been performed after either a delivery or abortion.

References

Barta, Ann and Ann Zeisset. Root Operations: Key to Procedure Coding in ICD-10-PCS. Chicago, IL: AHIMA Press, 2011.

Centers for Medicare and Medicaid Services. "2013 Code Tables and Index." 2012. http://www.cms.gov/Medicare/Coding/ICD10/2013-ICD-10-PCS-GEMs.html.

Centers for Medicare and Medicaid Services. "2013 ICD-10-PCS Official Guidelines for Coding and Reporting." 2013. http://www.cms.gov/Medicare/Coding/ICD10/Downloads/pcs_2013_guidelines.pdf.

Centers for Medicare and Medicaid Services. "2013 ICD-10-PCS Reference Manual." 2013. http://www.cms.gov/Medicare/Coding/ICD10/2013-ICD-10-PCS-GEMs.html.

Ann Barta (ann.barta@ahima.org) is a director of HIM practice excellence at AHIMA.