Health Information Management

Sew up your knowledge of root operation Repair

HIM-HIPAA Insider, November 10, 2014

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Welcome to OR 13 at the Stitch ‘Em Up Hospital, where Dr. Hack N. Slash is preparing for today’s procedure. And what is today’s procedure? Dr. Slash is performing a cut down and suturing of a pseudoaneurysm.
OK, what’s that? Well, a pseudoaneurysm is a hematoma adjacent to a hole or other disruption of the arterial wall. If you know your Greek, you know that “pseudo” means false. An aneurysm is a balloon-like bulge in an artery. So instead of the pseudoaneurysm being a bulge in an artery, the blood is actually collecting outside the arterial wall. Not a good thing.
A pseudoaneurysm is caused by blood slowly leaking into the surrounding tissue. It can happen pretty much anywhere you have an artery (which is pretty much everywhere in your body).
Pseudoaneurysms can also occur in the heart after damage from a heart attack causes blood to leak and pool outside the injured heart muscle.
The first thing we need to know is where the pseudoaneurysm is. That will give us our second character for our ICD-10-PCS code. The first character will be a 0 (zero, not a capital letter o) for the Medical and Surgical section. This is the biggest section of the ICD-10-PCS Manual and the one most non-OB coders will use the most.
Dr. Slash documents that the patient’s left leg is prepped and draped in a sterile fashion and he makes an incision to expose the femoral artery. That gives us lower artery as the body system (second character 4) and left femoral artery for the body part (fourth character L).
But we still need a third character, which is our root operation. What is the intent of this procedure? Well, Dr. Slash is attempting to remove blood from the patient’s leg, so maybe it’s Drainage (third character 9).
ICD-10-PCS defines Drainage as “taking or letting out fluids and/or gases from a body part.” Is Dr. Slash’s intention really just to remove the blood? Let’s check the OP report.
Under objective, Dr. Slash states he is suturing the artery to return it to its normal function. OK, so not Drainage. Dr. Slash’s objective isn’t to remove the blood. It’s to suture the hole in the artery to stop the leak. Which other root operation fits?
Turns out, it’s the “not elsewhere classified” (NEC) root operation Repair (restoring, to the extent possible, a body part to its normal anatomic structure and function).
We only use Repair (third character Q) when the method to accomplish the restoration is not one of the other root operations. That’s what makes it the NEC of root operations. If you’ve worked in the outpatient world at all, you are familiar with modifier -59 (distinct procedural service). You only append that modifier if no other modifier is more appropriate. Repair is the same way. You only report Repair when none of the other root operations describe the procedure.
Now we can head to the table because we have our first three characters: 04Q.
We already know the body part, so our code so far is 04QL. Notice that we have a different body part for the right femoral artery, along with:
  • Abdominal aorta
  • Celiac artery
  • Gastric artery
  • Hepatic artery
  • Splenic artery
  • Superior mesenteric artery
  • Colic artery (right, left, and middle)
  • Renal artery (right and left)
  • Inferior mesenteric artery
  • Common iliac artery (right and left)
  • Internal iliac artery( right and left)
  • External iliac artery (right and left)
  • Popliteal artery (right and left)
  • Anterior tibial artery (right and left)
  • Posterior tibial artery (right and left)
  • Peroneal artery (right and left)
  • Foot artery (right and left)
That is not by any means an exhaustive list of lower arteries, so we also have a body part character for “lower artery.”
You need to carefully read the body of the OP report to make sure the physician is actually performing the procedure he or she listed in the objective section. Sometimes surgeons need to change the procedure or sometimes they need to add a procedure.
The artery list is very specific, so if your surgeons are not this precise in their documentation, start working with them now on the added specificity. Chances are surgeons are documenting this somewhere in the OP report. You just may need to dig for it. (And make sure you scour the record before you fire off that query for location. No need to unnecessarily anger the surgeon.)
Back to our code. We have three choices for the approach:
  • 0, open
  • 3, percutaneous
  • 4, percutaneous endoscopic
Dr. Slash documented making an incision down to the artery to visualize the hole, so our approach is open (cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure).
Our final two characters are a snap because we only have one option for each:
  • Z, no device
  • Z, no qualifier
Our final code is 04QL0ZZ (repair left femoral artery, open approach).
All that’s left now is to sew up the patient and send him off to recovery.
This article originally appeared on HCPro’s ICD-10 Trainer blog.

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