Coding Root Operations with ICD-10-PCS: Understanding Division, Release, Control, and Repair

By Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA

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

The transition to ICD-10-CM/PCS on October 1, 2014 is much more than just the customary annual update of codes. The ICD-10-CM code set is very similar in structure to ICD-9-CM diagnosis codes, and shares many of the same conventions and guidelines. However, ICD-10-PCS is a unique classification system that introduces many changes and challenges for coding professionals.

One of the keys to understanding ICD-10-PCS are the many new definitions and descriptions used to describe the various components of a performed procedure. This article focuses on the definitions of four of the root operations-Division, Release, Control, and Repair-in the Medical and Surgical section.

Two of the root operations are used to define procedures involving cutting or separation only. Those two root operations, along with their corresponding character in ICD-10-PCS, are:

• Division: Character 8
• Release: Character N

Two of the root operations are used to define procedures that define other repairs. Those two root operations, along with their corresponding character in ICD-10-PCS, are:

• Control: Character 3
• Repair: Character Q

Root Operation 8: Division

The ICD-10-PCS definition provided in the 2013 ICD-10-PCS Reference Manual for the root operation Division is “Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part.” Division is coded when all or a portion of the body part is separated into two or more portions.

Some examples of Division procedures are spinal cordotomy, osteotomy, and division of the bundle of HIS.

For example, a percutaneous division of the left Achilles tendon is coded to 0L8P3ZZ. The characters are defined as follows:

• 0 – Medical and Surgical (section)
• L – Tendons (body system)
• 8 – Division (root operation)
• P – Lower Leg Tendon, Left (body part)
• 3 – Percutaneous (approach)
• Z – No Device (device)
• Z – No Device (qualifier)

The root operation Division is coded when the objective of the procedure is to cut into, transect, or otherwise separate all or a portion of a body part. When the objective is to cut or separate the area around a body part, the attachments to a body part, or between subdivisions of a body part that are causing abnormal constraint, the root operation Release is coded instead.

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

Open osteotomy of the right tibia

In ICD-9-CM, the Alphabetic Index entry main term, Osteotomy, subterm tibia with closed biopsy identifies code 77.37, Division of tibia/fibula.

In ICD-10-PCS, the coder must remember to identify the root operation that describes the main objective of the procedure. There is an index entry for Osteotomy, which leads the coder to Division, Lower Bones 0Q8. The correct code is 0Q8G0ZZ, Division of right tibia, open approach. The ICD-10-PCS code is more specific than the ICD-9-CM code in that it describes the specific bone divided (right tibia), as well as the approach (open).

Root Operation N: Release

According to the 2013 ICD-10-PCS Reference Manual, the definition of Release is “freeing a body part from an abnormal physical constraint by cutting or by use of force.” The objective of Release procedures is to free a body part from abnormal constraint. Release procedures are coded to the body part being freed. The procedure can be performed on the area around a body part, on the attachments to a body part, or between subdivisions of a body part that are causing the abnormal constraint.

Some examples of Release procedures are adhesiolysis and carpal tunnel release.

Code 0DNA4ZZ is an example of a Release code that describes a laparoscopic lysis of adhesions surrounding the jejunum. The characters are defined as follows:

• 0 – Medical and Surgical (section)
• D – Gastrointestinal System (body system)
• N – Release (root operation)
• A – Jejunum (body part)
• 4 – Percutaneous Endoscopic (approach)
• Z – No Device (device)
• Z – No Device (qualifier)

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

Carpal tunnel release, percutaneous

In the ICD-9-CM Alphabetic Index locate the main term “release,” followed by subterm “carpal tunnel (for nerve decompression)” which identifies code 04.43, Release of carpal tunnel.

In ICD-10-PCS, the main term entry of “release” requires the coder to select the body part being released. It is necessary to know that the median nerve is released during a carpal tunnel release. The body part value assigned is the structure released (median nerve) and not the structure cut (carpal ligament) to obtain the release. The subterm “nerve, median” below the main term “release” leads to 01N5. The 01N table is then accessed to construct the remainder of the code. The code assigned for a percutaneous release of the median nerve is 01N53ZZ.

Root Operation 3: Control

The definition provided in the 2013 ICD-10-PCS Reference Manual for Control is “stopping or attempting to stop, postprocedural bleeding.” Control is used to represent a small range of procedures performed to treat postprocedural bleeding. If one of the following procedures are required to stop the bleeding, Control is not coded separately:

• Bypass
• Detachment
• Excision
• Extraction
• Reposition
• Replacement
• Resection

Examples of Control procedures include control of post-prostatectomy hemorrhage and control of post-tonsillectomy hemorrhage.

Control of postoperative retroperitoneal bleeding via laparotomy is coded as 0W3H0ZZ. The characters are defined as follows:

• 0 – Medical and Surgical (section)
• W – Anatomical Regions, General (body system)
• 3 – Control (root operation)
• H – Retroperitoneum (body part)
• 0 – Open (approach)
• Z – No Device (device)
• Z – No Device (qualifier)

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

Fulguration of post-tonsillectomy hemorrhage

In the ICD-9-CM Alphabetic Index locate the main term “control,” followed by subterms “hemorrhage, tonsils (post-operative)” which results in code 28.7, Control of hemorrhage after tonsillectomy and adenoidectomy.

In ICD-10-PCS, index the main term of “control postprocedural bleeding in” followed by the subterm “oral cavity and throat” which provides the first four characters of the code: 0W3G. The approach to the tonsils is External (X) since the tonsils are visible without the aid of any instrumentation (ICD-10-PCS Coding Guideline B5.3a). The code assigned for this case is 0W33XZZ, Control bleeding in oral cavity and throat, external approach.

Root Operation Q: Repair

Repair is defined in the 2013 ICD-10-PCS Reference Manual as “Restoring, to the extent possible, a body part to its normal anatomic structure and function.” The root operation Repair represents a broad range of procedures for restoring the anatomic structure of a body part such as suture of lacerations. Repair also functions as the Not Elsewhere Classified (NEC) root operation, to be used when the procedure performed does not meet the definition of one of the other root operations. Fixation devices are included for procedures to repair the bones and joints.

Some examples of Repair procedures are colostomy takedown, herniorrhaphy, and suture of laceration.

Code 0HQBXZZ is an example of a Repair code that describes a suture of skin laceration of the right upper arm. The characters are defined as follows:

• 0 – Medical and Surgical (section)
• H – Skin and Breast (body system)
• Q – Repair (root operation)
• B – Skin, Right Upper Arm (body part)
• X – External (approach)
• Z – No Device (device)
• Z – No Device (qualifier)

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

Laparoscopic repair of right direct inguinal hernia

In the ICD-9-CM Alphabetic Index locate the main term “repair,” followed by subterms “inguinal, direct (unilateral), other and open (laparoscopic without graft or prosthesis” which directs the coder to code 53.01, Other and open repair of direct inguinal hernia. Notice that this procedure description includes diagnostic information (i.e., direct inguinal hernia), which is never found in ICD-10-PCS codes.

In ICD-10-PCS, locate the main term entry of “repair” followed by the subterms “inguinal region, right” which provides the first four characters of the code: 0YQ5. It’s important to note that had mesh been used with this procedure, the root operation would be Supplement rather than Repair. The correct code is 0YQ54ZZ, Repair right inguinal region, percutaneous approach.

References

Barta, Ann et al. ICD-10-PCS Coder Training Manual 2013 Instructor’s Edition. Chicago, IL: AHIMA Press, 2013.

Centers for Medicare and Medicaid Services. “2013 Code Tables and Index.” 2012. https://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. https://www.cms.gov/Medicare/Coding/ICD10/Downloads/pcs_2013_guidelines.pdf.

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

OptumInsight. “ICD-9-CM Expert for Hospitals and Payers, Volumes 1, 2, & 3 – 2013, First Edition.” Salt Lake City, UT: OptumInsight, 2012.

Melanie Endicott (melanie.endicott@ahima.org) is a director of HIM practice excellence at AHIMA.