Root Operations Medical and Surgical

ICD-10-PCS codes are used to report procedure performed in the inpatient setting, with the greatest number of codes being assigned from the Medical and Surgical section. 

In the Medical and Surgical section of ICD-10-PCS, root operation is the third character of the code and describes the intent or the objective of the procedure. There are 31 root operations in this section.  The entire list of root operations, with definitions, explanations and examples can be found in the ICD-10-PCS code manual.

These 31 root operations from the Medical and Surgical section can be divided into groups based on similar attributes. Below is a list showing each group and which root operations each includes.

ICD-10-PCS Medical and Surgical Section - Root Operation Groups

• Root operations that take out some or all of a body part include Excision, Resection, Detachment, Destruction, and Extraction.
• Root operations that take out solids/fluids/gases from a body part include Drainage, Extirpation, and Fragmentation.
• Root operations involving cutting or separation only include Division and Release.
• Root operations that put in/put back or move some/all of a body part include Transplantation, Reattachment, Transfer, and Reposition.
• Root operations that alter the diameter/route of a tubular body part include Restriction, Occlusion, Dilation, and Bypass.
• Root operations that always involve a device include Insertion, Replacement, Supplement, Change, Removal, and Revision.
• Root operations involving examination only include Inspection and Map.
• Root operations that define other repairs include Control and Repair.
• Root operations that define other objectives include Fusion, Alteration, and Creation.

Some notes about root operations:

• In order to determine the appropriate root operation, the full definition of the root operation as contained in the PCS Tables must be applied. (ICD-10-PCS Coding Guideline B3.1a)
• It is the coder’s responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear (ICD-10-PCS Convention A11).

Example: When the physician documents “partial resection” the coder can independently correlate “partial resection” to the root operation Excision without querying the physician for clarification.

References

• ICD-10-PCS code book
• ICD-10-PCS: An Applied Approach
  
  

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.