Presented by:Kathy L. Hallock, RHIA, CDIP, AHIMA I 10 Certified Trainer

Root Operation – Overview

Root Operation --- 6

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Body System

Section Root Root OperationOperation

Body PartBody Part

Approach

Device

QualifierQualifier

Objective of the procedure

Third character in the procedure code

ICD-10-PCS: Appendix B

31 root operations

9 Groups that share similar attributes

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There is a specific definition for each of these roots. The full definition of the root operation must be

applied

ICD-10-PCS uses terminology that coders are not accustomed to seeing on a daily basis in records.

The purposes of this training is to help the coder smoothly transition to the new root operations and their meanings.

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Take out some or all of a body part Take out solids/ fluids/gases from a body part Involve cutting or separation only Put in/put back or move some or all of a body

part Alter the diameter or route of a tubular body part Always involve a device Involve examination only Involve other repairs Involve other objectives

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Procedures that always involve

devices

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Insertion – Putting in a non-biological appliance that monitors, assists, performs or prevents a physiological function but does not physically take the place of a body part.

Replacement – Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part.

Supplement- Putting in or on biologic or synthetic material that physically reinforces and/or augments the function of a portion of a body part.

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Change – Taking out or off a device from a body part and putting back an or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane

Removal – Taking out or off a device from a body part.

Revision – Correcting, to the extent possible, a malfunctioning or displaced device

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13Image: mayoclinic.org

14Image: urogyn-nj.com

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16Image: breastcancer.org

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InspectionMap

Visually and/or manually exploring a body part.

Visual exploration may be performed with or without optical instrumentation. Manual exploration maybe performed directly or through intervening body layers

Example: Diagnostic bronchoscopy of the left upper lobe

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Inspection of a body part(s) integral to the performance of the procedure is not coded separately.

Example: Fiberoptic bronchoscopy with irrigation of bronchus, only the irrigation procedure is coded.

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Inspection of Multiple Parts: ◦ If multiple non-tubular body parts are inspected, body

part character is defined as the general body part value that identifies the entire area inspected.

◦ If multiple tubular parts are inspected, the body part character is defined as the most distal body part inspected.

Example: Cystourethroscopy with inspection of the bladder and ureters is coded to the ureter body part value.

Exploratory laparotomy with general inspection of abdominal contents is coded to the Peritoneal Cavity body part value.

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Inspection with another Procedure

◦ When both an inspection procedure and another procedure are performed on the same body part during the same episode, if the inspection procedure is performed using a different approach than the other procedure, the inspection procedure is coded separately.

◦ Example – Percutaneous endoscopic inspection of the small intestine during a procedure in which open excision of the duodenum is performed.

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Gastrointestinal Body System General body part values Upper Intestinal

and Lower Intestinal Tract are provided as an option for Change, Inspection, Removal and Revision

Upper Intestinal Tract includes from the esophagus down to and including duodenum

Lower Intestinal Tract includes from the jejunum down to and including the rectum and anus

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Coding Note: Procedures that are discontinued without any other root operation being performed are coded to inspection.

Locating the route of passage of electrical impulses and/or locating functional areas in a body part

Examples: Cardiac mapping, cortical mapping, cardiac electrophysiological study (EPS)

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Mapping procedures include only cardiac mapping and cortical mapping.

Coding Note: The only 2 Body Systems under Map are the Central Nervous System (00K) and Heart and Great Vessels (02K).

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ICD 10 makes no sense?????

My wheels are turning, I think I’m getting it!!!!!!!

Your brain on I-9

Your brain on I-10

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