In-depth comprehension of anatomy is now required for successful coding of surgical procedures in ICD-10-PCS.
Question: Our team struggles to identify the correct root operation in ICD-10-PCS. How can coding managers help their staff master root operations?
Answer: Coding root operations in ICD-10-PCS continues to cause ripples among coding professionals. Across dozens of educational webinars and ICD-10 training tips, the topic of root operations always surfaces as a top coding concern. Here’s why.
In ICD-9-CM, the classification system was exact in terms of concepts and anatomy comprehension. For example, an excision was an excision. There was no need to code whether the intent of the excision was to remove an entire organ or only a part of the organ. Coding the “intent” of a surgical procedure involves a new thought process for coding professionals to master; hence the confusion and ongoing struggle.
To help your coders identify the correct root operation in ICD-10-PCS, promote understanding of the following fundamentals.
Incision and Drainage
When a provider performs an incision and drainage on skin or subcutaneous tissue/fascia, various root operations may be performed. Coders should understand the intent of the procedure by carefully reviewing the clinical documentation. It is important to remember that more than one root operation may be performed during a single surgical episode. The possible selections to identify the intent of incision and drainage procedures include:
- Drainage–drainage of an abscess
- Extirpation–removal of a foreign body
- Excision–excisional debridement
- Destruction–cauterizing bleeding or lesions
- Extraction–nonexcisional debridement
- Repair–suture of a vessel, ligament, muscle, tendon, etc.
Another area of confusion is depth of tissue involved in incision and drainage procedures. When multiple layers are involved, code only the deepest level. Also, when overlapping body layers are involved, code the body part specifying the deepest layer. Tissue involvement options are the following:
- Skin
- Subcutaneous tissue/fascia
- Muscle
- Ligaments/bursa
- Tendons
- Joints
- Bone
For example, if excisional debridement is performed on skin, subcutaneous tissue/fascia, and muscle, code only excision of muscle.
Excision Versus Drainage For Biopsy Purposes
We also receive frequent questions regarding whether excision or drainage is performed during biopsies. In general, if fluid or gases are aspirated or drained, then drainage is the appropriate root operation. Examples include drainage of an abscess, paracentesis, thoracentesis, and needle aspiration of abscess or other fluids. If tissue is excised, then excision is the appropriate root operation.
Insertion of Devices
When the surgical procedure requires insertion of a device, coding of the root operation should describe the reason or intent for the insertion, not just “insertion.” This is another common point of confusion and error for professional coders because device insertions serve many purposes and perform many functions.
The official coding guidelines provide specific definitions for each type of device insertion. Periodically, these should be carefully reviewed with the coding team to ensure consistency and accuracy. Examples include dilation, replacement, drainage, supplement, restriction, occlusion, and bypass. When coding a device insertion, coders should keep in mind the purpose of the device being inserted and the root operation it is meant to perform.
Intent and Objective are Key
The root operation identification is based on the intent and objective of the procedure. This requires a shift in thinking. Coders should first determine what the provider intends to accomplish. This is critical to ensuring complete and accurate clinical documentation.
For the past 37 years, coders have not had to identify the difference between an excision or resection procedure, nor have they had to ask, “What is this device meant to accomplish?”
In-depth comprehension of anatomy is now required for successful coding of surgical procedures in ICD-10-PCS. Consistent education to reinforce understanding of the fundamentals is a mainstay for all ICD-10 coding teams.
