The International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) is a coding system used to classify procedures performed in hospital inpatient settings in the United States. One of the key components of the ICD-10-PCS coding system is the root operation, which describes the objective of the procedure performed. In this guide, we will provide an overview of the root operations in ICD-10-PCS and how they are used in coding.
What are Root Operations in ICD-10-PCS?
The root operation is the third character in an ICD-10-PCS procedure code and describes the objective of the procedure performed. There are 31 root operations in ICD-10-PCS, which are divided into seven groups based on the type of objective they represent:
- Inspection: This group of root operations includes procedures that involve visually or manually examining a body part or area.
- Repair: This group of root operations includes procedures that involve restoring or fixing a body part or area.
- Removal: This group of root operations includes procedures that involve taking out or excising a body part or area.
- Replacement: This group of root operations includes procedures that involve substituting or exchanging a body part or area.
- Reposition: This group of root operations includes procedures that involve moving a body part or area to a different position or location.
- Transfer: This group of root operations includes procedures that involve moving a body part or area from one location to another.
- Alteration: This group of root operations includes procedures that involve modifying or changing the function or appearance of a body part or area.
Each root operation has a unique definition and set of guidelines that must be followed when selecting the appropriate code.
How are Root Operations Used in Coding?
When coding a procedure using ICD-10-PCS, the root operation is the starting point for selecting the appropriate code. The root operation is selected based on the objective of the procedure performed. Once the root operation is selected, the coder must then choose additional characters to specify the body part or area involved in the procedure, the approach used to perform the procedure, and any devices used during the procedure.
For example, if a patient undergoes a procedure to remove a portion of their small intestine, the root operation would be “Excision” from the Removal group. The coder would then select additional characters to specify the specific portion of the small intestine removed, the approach used to perform the procedure, and any devices used during the procedure.
It is important for coders to carefully review the definitions and guidelines for each root operation to ensure that the correct code is selected. Using the wrong root operation can result in an inaccurate code that does not reflect the objective of the procedure performed.
Tips for Selecting the Correct Root Operation
Selecting the correct root operation in ICD-10-PCS requires a thorough understanding of the definitions and guidelines for each root operation. Here are some tips to help ensure that the correct root operation is selected:
- Read the definitions carefully: Each root operation has a unique definition that describes the objective of the procedure performed. It is important to read the definitions carefully and select the root operation that best describes the objective of the procedure.
- Follow the guidelines: In addition to the definitions, each root operation has a set of guidelines that must be followed when selecting the appropriate code. Be sure to review these guidelines carefully and follow them when selecting the code.
- Consider the approach and devices used: When selecting the root operation, it is important to consider the approach and devices used during the procedure. This information can help determine which root operation best describes the objective of the procedure.
- Check for exclusions: Some root operations have exclusions that limit their use in certain circumstances