Health Information Management

Tip: Root operations terminology will make a difference in ICD-10 coding

CDI Strategies, July 21, 2011

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ICD-10-PCS codes include one digit for the root operation that the provider performs. The root operation is always the third character in the seven-character code. The definitions of these root operations are consistent across other sections of ICD-10-PCS, although they may be represented by different characters in different sections.
 
Some root operations sound similar but actually indicate slightly different procedures, such as excision, resection, and detachment. An excision involves cutting out a portion of a body part, but a resection involves cutting out all of a body part. Detachment is the cutting off of all or a portion of the upper or lower extremities.
 
Because a provider may use the word “excision” when he or she actually performs a resection, coders will need to carefully read the operative note to determine what was actually performed. CDI specialists should be aware of these changes and start reviewing the definitions of the various root operations. By learning the root operations early, CDI staff will have a head start on understanding coding nuances and helping physicians improve their documentation accordingly.
 
Editor’s Note: This article was originally published on the HCPro Blog ICD-10 Trainer.



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