ROOT OPERATIONS Flashcards
EXCISION
DEFINITION: Cutting out or off, without replacement, a portion of a body part
EXPLANATION: The qualifier DIAGNOSTIC is used to identify excision procedures that are biopsies
***Bone Marrow & Endometrial Biopsies are coded to EXTRACTION with the qualifier DIAGNOSTIC
EXAMPLES: Partial nephrectomy, liver biopsy, breast lumpectomy, breast reduction for medical reasons (for cosmetic reasons is ALTERATION), Excisional Debridement (non-Excisional Debridement is EXTRACTION)
ALTERATION
Modifying the natural anatomic structure of a body part without affecting the function of the body part
BYPASS
DEFINITION: Altering the route of passage of the contents of a tubular body part
EXPLANATION: Rerouting content 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 mor asastomoses, with or without the uses of a device. Bypass procedures are coded by identifying the body part bypassed “from” and the body part bypassed “to”. The 4th character body part specifies the body part bypassed from and the qualifier specifies the body part to.
EXAMLPLES: Coronary bypass graft (CABG), Colostomy formation
CHANGE
DEFINITION: Taking 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 mucous membrane. Represents only those procedures where a similar device is exchanged without making a new incision or puncture.
EXPLANATION: All Change procedures are coded using the approach External
EXAMPLES: Urinary catheter change, gastrostomy tube change, drainage tube change
CONTROL
DEFINITION: Stopping, or attempting to stop, post-procedural bleeding
EXPLANATION: The site of the bleeding is coded as an anatomical region and not to a specific body part. Control is used to represent a small range of procedures performed to treat post-procedural bleeding. If any of the following procedures. Are required to stop the bleeding, Control so NOT coded separately: 🔴 Bypass 🔴 Detachment 🔴 Excision 🔴 Extraction 🔴 Reposition 🔴 Replacement 🔴 Resection if they do any of these procedures you can't code control!
EXAMPLES: Control of post-prostatectomy hemorrhage, control of post-tonsillectomy hemorrhage. Control includes irrigation or evacuation of hematoma done at the operative site. Both irrigation and evacuation may be necessary to clear the operative field and effectively stop the bleeding.
CREATION
Making a new genital structure that does not take over the function of a body part
DESTRUCTION
DEFINITION: Physical eradication of all or a portion of a body part by the direct use of energy, force, or destructive agent
EXPLANATION: None of the body part is physically taken out
EXAMPLES: Fulguration of rectal polyp, cautery of skin lesion, Fulguration of endometrium
DETACHMENT
DEFINITION: Cutting off all or a portion of the upper or lower extremities
EXPLANATION: The body part value is the site of the detachment, with a qualifier, if applicable, to further specify the level where the extremity was detached
EXAMPLE: Below-knee amputation, disarticulation of shoulder, amputation above elbow
DILATION
DEFINITION: Expanding an orifice or the lumen of a tubular body part
EXPLANATION: The orifice can be a natural or an artificially created oriffice. Accomplished by stretching a tubular body part using intraluminal pressure or by cutting part of the office or wall of the tubular body part. A device placed to maintain the new diameter is an integral part of dilation procedure, and is coded to the 6th character device value in the value in the dilation procedure code.
EXAMPLES: Percutaneous transluminal angioplasty, Percutaneous transluminal coronary angioplasty (PTCA), laryngeal stenosis dilation, dilation common bile duct.
DIVISION
DEFINITION: Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part
EXPLANATION: All or a portion of the body part is separated into two or more portions. If the sole objective of the procedure is separating or transecting a body part, the root operation is division, ie., severing a nerve root to relieve pain
EXAMPLES: Spinal cordotomy, osteotomy, neurotomy, episiotomy
DRAINAGE
DEFINITION: Taking or letting out fluids and/or gases from a body part
EXPLANATION: The qualifier DIAGNOSTIC is used to identify drainage procedures that are biopsies
EXAMPLES: Thoracentesis, Incison & Drainage, Aspiration, Lumbar puncture
EXTIRPATION
DEFINITION: Taking or cutting out solid matter from a body part
EXPLANATION: The solid matter may be an abnormal byproduct of a biological function or a foreign body; it may be imbedded in a body part, or in the lumen of a tubular body part. The solid matter may or may not have been previously broken into pieces.
EXAMPLES: Thrombectomy, endarterectomy, choledocholithotomy, excision foreign body. The objective of the procedure is to remove solid material such as a foreign body, thrombus, or calculus from the body part.
***ESWL can be either an EXTIRPATION or FRAGMENTATION
EXTRACTION
DEFINITION: Pulling or stripping out or off all or a portion of a body part by the use of force
EXPLANATION: The qualifier DIAGNOSTIC is used to identify extraction procedures that are biopsies
EXAMPLES: Dilation and Curettage, vein stripping, phacoemulsification WITHOUT IOL implant (phacoemulsification with IOL implant is REPLACEMENT), non-excisional debridement (excisional debridement is EXCISION), liposuction for medical reasons (liposuction for cosmetic reasons is ALTERATION), removal of a thumbnail
FRAGMENTATION
DEFINITION: Breaking solid matter in a body part into pieces
EXPLANATION: The physical force (ie., manual ultrasonic) applied directly or indirectly is used to break the solid matter into pieces. The solid matter my be an abnormal byproduct of a biological function or a foreign body. The pieces of solid matter are not taken out.
EXAMPLES: Extracorporeal shockwave lithotripsy, transurethral lithotripsy. Fragmentation is coded for procedures to break up, but not remove solid material such as calculus or foreign body.
***ESWL can be either an EXTIRPATION or FRAGMENTATION
FUSION
Joining together portions of an articular body part rendering the articular body part immobile
INSERTION
DEFINITION: Putting in a nonbiological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part
EXPLANATION: the sole objective of the procedure is to put in a device without doing anything lead to a body part. procedures typical of those coded to insertion include putting in a vascular catheter, pacemaker lead, or tissue expander. PICC LINES, CENTRAL LINES
EXAMPLES : Insertion of radioactive implant, insertion of central venous catheter.
INSPECTION
DEFINITION: Visually and/or manually exploring a body part
EXPLANATION: Visual exploration may be performed with or without optical instrumentation. Manual exploration may be performed directly or through intervening body layers. The sole objective of the procedure is to examine a body part. Procedures that are discontinued without any other root operation being performed are also coded to Inspection.
EXAMPLES: Diagnostic arthroscopy, exploration laparotomy, diagnostic cystoscopy.
MAP
DEFINITION: Locating the route of passage of electrical impulses and/or locating functional areas in a body part
EXPLANATION: Applicable only to the cardiac conduction mechanism and the central nervous system.
EXAMPLES: Cardiac mapping, cortical mapping, cardiac electro physiological study.
OCCLUSION
DEFINITION: Completely closing an orifice or lumen of a tubular body part
EXPLANATION: Theorifive can be a natural orifice or an artificially created one. Used when the one time of the procedure is to close off a tubular body part or orifice. Division of the tubular body part prior to closing it is an integral part of the Occlusion procedure
EXAMPLES: Fallopian tube ligation, ligation of inferior vena cava
***Tumor embolization is coded to Occlusion because the objective is to cut off the blood supply to the vessel. Embolization of a cerebral aneurysm is coded to Restriction because the objective of the procedure is not to close off the vessel entirely but to narrow the lumen of the vessel at the site of the aneurysm where it is abnormally wide.
REATTACHMENT
DEFINITION: Putting back in or on all or a portion of a separated body part to its normal location or other suitable location
EXPLANATION: Vascular circulation and nervous pathways may or may not be resets listed
EXAMPLES : REATTACHMENT of hand, REATTACHMENT of avulsed kidney, REATTACHMENT of finger
RELEASE
DEFINITION: Freeing a body part from an abnormal physical constraint by cutting or by use of force
EXPLANATION: some of the restraining tissue may be taken out but NONE of the body part is taken out
EXAMPLES: Adhessiolysis, carpal tunnel release, manipulation of joint adhesions. Release is to free a body part from abnormal constraints. Release procedures are coded to the body part being freed. The procedure can be performed on the area around the body part, on the attachment to a body part, or between subdivisions of a body part that are causing the abnormal constraint.
REMOVAL
DEFINITION: Taking out or off a device from a body part
EXPLANATION: If the device is taken out and a similar device is 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 the device is coded to the root operation Removal. A procedure to remove a device is coded to removal if it is NOT an integral part of another root operation and regardless of the approach or the original root operation by which the device was put in.
EXAMPLE: Drainage tube removal, cardiac pacemaker removal, central line removal.
REPAIR
Restoring, to the extent possible, a body part to its normal anatomic structure and function
REPLACEMENT
DEFINITION: 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. Replacement includes taking out the body part.
EXPLANATION: The body part may have been taken out or replaced,or may be taken out, physically eradicated, ore endeared nonfunctional during the Replacement procedure. A removal procedure is coded
for taking out the device used in a previous replacement procedure.
EXAMPLES: Total hip replacement, bone graft, free skin graft, phacoemulsification with IOL implant (phaco without IOL implant is Extraction., heart valve replacement, replacement cornea, free TRAM
***The objective of procedures coded to the root operation Replacement Is to put in a device that takes the place of some or all of the body part. Replacement encompasses a wide range of procedures, from joint replacement to grafts of all kinds.
REPOSITION
DEFINITION: Moving to its normal location or other suitable location all or a portion of a body part
EXPLANATION: The body part is moved to a new location from an abnormal location, or from a normal location where it is not functioning correctly. The body part may or may not be cut out or off to be moved to the new location.
EXAMPLES: Reposition of u descended testicle, fracture reduction. The diagnosis in ICD-10 would reflect that a displaced fracture is being reduced when Reposition is used.
***Putting in a pin in a no displaced fracture is coded to the root operation insertion. Casting of a non displaced fracture is coded to the root operation Immobilization in the placement section.
RESECTION
DEFINITION: Cutting out or off, without replacement, all of a body part
EXAMPLES: Total nephrectomy, total lobe tommy of lung, total mastectomy
***When an ENTIRE lymph chain is cut out, the appropriate root operation is RESECTION. When ONE lymph node(s) is cut out, the root operation is EXCISION
RESTRICTION
DEFINITION: Partially closing an orifice or lumen of a tubular body part. Restriction includes either intraluminl or extralumenal methods for narrowing the diameter.
EXPLANATION: The orifice can be a natural orifice or an artificially created oriffice
EXAMPLES : Esophagogastric fundoplication, cervical cerci age
REVISION
DEFINITION: Correcting, to the extent possible, a portion of a malfunctioning device or the position of a displaced device
EXPLANATION: Revision can include correcting a malfunctioning device by taking out and/or putting in part of the device. The objective of the procedure is to correct the positioning or function of a previously placed device, without taking the entire device out and putting a whole new device in its place. A complete re-do of the original root operation is coded to the root operation performed.
EXAMPLES: Adjustment of pacemaker lead, adjustment of hip prosthesis, revision of pacemaker insertion
SUPPLEMENT
DEFINITION: Putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part
EXPLANATION: The biological material is non-living, or is living and from the same individual. The body part may have been previously replaced, and the Supplement procedure is performed to physically reinforce and/or augment the function of the replaced body part
EXAMPLES: Herniorrhaphy using mesh (Herniorrhaphy without mesh is Repair), free nerve graft, mitral valve ring annuloplasty, put a new ace tabular liner in a previous hip replacement, abdominal wall Herniorrhaphy using mesh.
TRANSFER
DEFINITION: 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
EXPLANATION: The body part transferred remains connected to its vascular and nervous supply
EXAMPLES: Tendon transfer, skin pedicle flap transfer, skin transfer flap
**Free grafts are coded to root operation of Replacement
TRANSPLANTATION
DEFINITION: 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
EXPLANATION: The native body part may or may not be taken out, and the transplanted body part may take over all or a portion of its function.
EXAMPLES: Kidney transplant , heart transplant
*****Qualifier values specify the compatibility of the body part transplanted, ie., allogeneic- taken from different individuals, syngenic- having to do with individuals or tissues that have identical genes ie., twins, zooplastic-tissue from an animal to a human
***Bone marrow transplant procedures are coded to Adminstration, transplantation
