Review the definition of selected root operations for the Medical and Surgical section and Obstetrics section of ICD-10-PCSIdentify the objective for selected root operations in the Medical and Surgical section and Obstetrics section of ICD-10-PCSReview special explanations for selected root operations in the Medical and Surgical section and Obstetrics section of ICD-10-PCSIdentify examples of selected root operations in the Medical and Surgical section and Obstetrics section of ICD-10-PCS
CHARACTER 1Section
CHARACTER 2Body System
CHARACTER 3Root Operation
CHARACTER 4Body Part
CHARACTER 5Approach
CHARACTER 6Device
CHARACTER 7Qualifier
Root Operations
Alteration Excision Release
Bypass Extirpation Removal
Change Extraction Repair
Control Fragmentation Replacement
Creation Fusion Reposition
Destruction Insertion Resection
Detachment Inspection Restriction
Dilation Map Revision
Division Occlusion Supplement
Drainage Reattachment Transfer
Transplantation
Excision (B)Cutting out or off, without replacement, a portion of a body part
Resection (T)Cutting out or off, without replacement, all of a body part
Extraction (D)Pulling or stripping out or off all or a portion of a body part by the use of force
Destruction (5)Physical eradication of all or a portion of a body part by the direct use of energy, force or a destructive agent
Detachment (6)Cutting off all or part of the upper or lower extremities
Transplantation (Y)Putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part
Reattachment (M)Putting back in or on all or a portion of a separated body part to its normal location or other suitable location
Reposition (S)Moving to its normal location or other suitable location all or a portion of a body part
Transfer (X)Moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part
Drainage (9)Taking or letting out fluids and/or gases from a body part
Extirpation (C)Taking or cutting out solid matter from a body part
Fragmentation (F)Breaking solid matter in a body part into pieces
Inspection (J)Visually and/or manually exploring a body part
Map (K)Locating the route of passage of electrical impulses and/or locating functional areas in a body part
DefinitionAltering the route of passage of the contents of a tubular body part
ExplanationRerouting contents of a body part to a downstream area of the normal route, to a similar route and body part, or to an abnormal route and dissimilar body part. Includes one or more anastomoses, with or without the use of a device
ExampleCoronary artery bypassColostomy formation
Which of the following would be an example of the root operation bypass?
Endoscopic radial to median nerve transferUrinary diversion, ureter, using ileal conduit to skinTracheostomy formation with tracheostomy tube placementPercutaneous transluminal angioplasty of brachial artery stenosisPercutaneous in-situ coronary venous arterialization (PICVA) of single coronary artery
DefinitionExpanding an orifice or the lumen of a tubular body part
ExplanationThe orifice can be a natural orifice or an artificially created orifice. Accomplished by stretching a tubular body part using intraluminalpressure or by cutting part of the orifice or wall of the tubular body part
ExamplePercutaneous transluminal angioplastyPyloromyotomy
Which of the following would be an example of the root operation dilation?
Percutaneous transluminal coronary angioplasty (PTCA)Transnasal dilation and stent placement lacrimalductHysteroscopy with dilation and curretagePyloromyotomyRoutine Foley catheter placement
DefinitionCompletely closing the orifice or lumen of a tubular body part
ExplanationThe orifice can be a natural orifice or an artificially created orifice
ExampleFallopian tube ligationLigation of inferior vena cava
Which of the following would be an example of the root operation occlusion?
Tumor embolization of meningiomaFemale sterilization using Falope ringsEmbolization of a cerebral aneurysmSuture ligation of failed AV graft of brachial arteryLigation of esophageal veinFemale sterilization by electrocoagulation of fallopian tube
DefinitionPartially closing the orifice or lumen of a tubular body part
ExplanationThe orifice can be a natural orifice or an artificially created orifice
ExampleEsophagogastric fundoplicationCervical cerclage
Which of the following would be an example of the root operation restriction?
Cautery of nosebleedComplete embolization of internal carotid –cavernous fistulaThoracotomy with banding of left pulmonary artery with extraluminal deviceCraniotomy with clipping of cerebral aneurysmNon-incisional, transnasal placement of restrictive stent in lacrimal duct
DefinitionPutting in a nonbiological appliance that monitors, assists, performs or prevents a physiological function but does not physically take the place of a body part
ExampleInsertion of radioactive implantInsertion of central venous catheter
Which of the following would be an example of the root operation insertion?
Percutaneous insertion of bone growth stimulator electrode, left femoral shaftCystoscopy with ureteral dilation and placement of ureteral stentPercutaneous transluminal coronary angioplasty with insertion of drug-eluting stentPercutaneous placement of intrathecal infusion pump for pain managementOpen insertion of multiple channel cochlear implant, right ear
DefinitionPutting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part
ExplanationThe body part may have been taken out or replaced, or may be taken out, physically eradicated, or rendered nonfunctional during the Replacement procedure. A Removal procedure is coded for taking out the device used in a previous replacement procedure
ExampleTotal hip replacement, bone graftFree skin graft
Which of the following would be an example of the root operation replacement?
Phacoemulsification of cataract of right eye with intraocular lens implantationOpen aortic valve replacment using porcine valveFoley catheter replacementLeft inguinal herniorrhaphy with Marlex meshOpen tenonectomy with graft to left ankle using cadaver graftTotal left knee arthroplasty with insertion of total knee prosthesis
DefinitionPutting in or on biological or synthetic material that physically reinforces or augments the function of a body part
ExplanationThe biological material is non-living, or the biological material is living and from the same individual. The body part may have been previously replaced. If the body part has been previously replaced, the Supplement procedure is performed to physically reinforce and/or augment the function of the replaced body part
ExampleHerniorrhaphy using meshFree nerve mitral valve ring annuloplastyPut a new acetabular liner in a previous hip replacement
Which of the following would be an example of the root operation supplement?
Open exchange of liner in right femoral component of previous hip replacementOpen abdominal wall hernia repair using synthetic meshExcision of abdominal aorta with Gore-Tex graft replacement, openPercutaneous endoscopic autograft nerve graft to left radial nerveCystoscopy with placement of brachytherapyseeds in prostate gland
DefinitionTaking out or off a device from a body part
ExplanationIf a device is taken out and a similar device put in without cutting or puncturing the skin or mucous membrane, the procedure is coded to the root operation Change. Otherwise, the procedure for taking out a device is coded to the root operation Removal
ExampleDrainage tube removalCardiac pacemaker removal
Which of the following would be an example of the root operation removal?
Removal of external fixator, left humeral head fractureRight wrist joint amputationCystoscopy with removal of right ureteral stent Removal of tattered ear drum fragments with tweezersTransurethral removal of brachytherapy seedsEndotracheal extubation
DefinitionTaking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane
ExplanationAll Change procedures are coded using the approach External
ExampleUrinary catheter changeGastrostomy tube change
Which of the following would be an example of the root operation change?
Repositioning of dislocated total hip replacement componentsExchange of chest tube for right pneumothoraxReplacement of malfunctioning pacemaker generatorFoley catheter replacementPercutaneous endoscopic gastrostomy (PEG) tube exchangeRemoval and replacement of drainage tube from left hip joint
DefinitionCorrecting, to the extent possible, a malfunctioning or displaced device
ExplanationRevision can include correcting a malfunctioning or displaced device by taking out or putting in components of the device such as a screw
ExampleAdjustment of position of pacemaker leadRecementing of hip prosthesis
Which of the following would be an example of the root operation revision?
Repositioning of Swan-Ganz catheter in superior vena cavaPartial-thickness skin graft to right lower leg, autograftRemoval of a loose screw and putting a larger screw in a fracture repair plate, left fibulaPercutaneous adjustment of position of left pacemaker lead in the left atriumIncision with removal of K-wire fixation, left second metacarpal
DefinitionCutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part
ExplanationAll or a portion of the body part is separated into two or more portions
ExampleSpinal cordotomyOsteotomy
Which of the following would be an example of the root operation division?
Percutaneous tenotomy of left Achilles tendonEGD with esophagotomy of esophagogastricjunctionIncision and removal of right lacrimal duct calculusLaparoscopy with lysis of peritoneal adhesionsLeft heart catheterization with division of bundle of His
DefinitionFreeing a body part from an abnormal physical constraint by cutting or by use of force
ExplanationSome of the restraining tissue may be taken out but none of the body part is taken out
ExampleAdhesiolysisCarpal tunnel release
Which of the following would be an example of the root operation release?
Anal sphincterotomyIncision of scar contracture, left elbowManual rupture of left shoulder joint adhesions under general anesthesiaFrenulotomy for treatment of tongue-tie syndromeMitral valvulotomy for release of fused leaflets, openOpen osteotomy of capitate, right hand
DefinitionStopping, or attempting to stop, post-procedure bleeding
ExplanationThe site of the bleeding is coded as an anatomical region and not to a specific body part
ExampleControl of post-prostatectomy hemorrhage Control of post-tonsillectomy hemorrhage
Which of the following would be an example of the root operation control?
Control of post-operative retroperitoneal bleeding via laparotomyExploration and ligation post-op arterial bleeder, forearmD&C for excessive bleeding following endometrial biopsyReopening thoracotomy site with drainage and control of post-operative hemopericardiumHysteroscopy with cautery of post-hysterectomy oozing and evacuation of clot
DefinitionRestoring, to the extent possible, a body part to its normal anatomic structure and function
ExplanationUsed only when the method to accomplish the repair is not one of the other root operations
ExampleColostomy takedown Suture of laceration
Which of the following would be an example of the root operation repair?
Perineoplasty with repair of old obstetric lacerationRight inguinal herniorrhaphyClosure abdominal wall stab woundLaparatomy with suture blunt force duodenal lacerationLeft inguinal herniorrhaphy with Marlex meshSuture radial nerve laceration
DefinitionModifying the anatomical structure of a body part without affecting the function of the body part
ExplanationPrincipal purpose is to improve appearance
ExampleFace liftBreast augmentation
Which of the following would be an example of the root operation alteration?
Open blepharoplasty of right and left lower eyelids for blepharoptosisCosmetic rhinoplasty with septal reduction and tip elevation, using local tissue graft, openAbdominal liposuction for cosmetic reasonsOpen abdominoplasty (tummy tuck)Open cosmetic blepharoplasty of right and left lower eyelidsFunctional rhinoplasty for restoration of airway
DefinitionJoining together portions of an articular body part rendering the articular body part immobile
ExplanationThe body part is joined together by fixation device, bone graft, or other means
ExampleSpinal fusionAnkle arthrodesis
DefinitionMaking a new genital structure that does not take over the function of a body part
ExplanationUsed only for sex change operations
ExampleCreation of vagina in a maleCreation of penis in a female
CHARACTER 1Section
CHARACTER 2Body System
CHARACTER 3Root Operation
CHARACTER 4Body Part
CHARACTER 5Approach
CHARACTER 6Device
CHARACTER 7Qualifier
Root Operations
Abortion Extraction Repair
Change Insertion Reposition
Delivery Inspection Resection
Drainage Removal Transplantation
DefinitionArtificially terminating a pregnancy
ExplanationSubdivided according to whether an additional device such as a laminaria or abortifacient is used, or whether the abortion was performed by mechanical means
ExampleTransvaginal abortion using vacuum aspiration technique
DefinitionAssisting the passage of the products of conception from the genital canal
ExplanationApplies only to manually assisted, vaginal delivery
ExampleManually assisted delivery
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