Health Information Management

Pick the correct root operation for a biopsy

HIM-HIPAA Insider, February 2, 2015

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We can choose from 31 root operations in the ICD-10-PCS Medical and Surgical section, but biopsy isn’t one of them. So which root operation do we use when a physician performs a biopsy?

The answer is, it depends.
We will select a root operation in ICD-10-PCS based on the intent of the procedure.
For example, Dr. Sharpe documents a thoracentesis, which is a procedure to remove fluid from the space between the lining of the outside of the lungs and the chest wall. For that procedure, we use root operation Drainage (taking or letting out of fluids and/or gases from a body part).
When it comes to coding a biopsy in ICD-10-PCS, we need to look at what the physician is actually removing.
Let’s say Betsy came in with a growth on her thyroid. Dr. Sharpe decides to perform a needle biopsy to see whether the growth is cancerous. For this type of biopsy, Dr. Sharpe is removing a small piece of Betsy’s thyroid for examination.
We would use root operation Excision because Dr. Sharpe’s intent is to cutting out, without replacement, a portion of a body part. We would use the same root operation for liver biopsies, breast biopsies, and any other biopsy that involves removing a piece of tissue.
To tell the payer Dr. Sharpe is removing the tissue for a biopsy, we would use the seventh character X (diagnostic). Make sure the ICD-10-PCS table you’re using includes X as an option for the seventh character.
Not all biopsies fall under Excision. Go back to the thoracentesis procedure we started with. Dr. Sharpe may be removing that fluid to perform a biopsy. We would still use root operation Drainage, we just need to use the diagnostic qualifier.
Then we have bone marrow biopsies. Bone marrow is spongy tissue inside some of your larger bones. Bone marrow functions as part of the lymphatic and hemic system. When Dr. Sharpe performs a bone marrow biopsy, he uses a specially designed needle to collect a core (cylindrical sample) of bone marrow.
We will code bone marrow biopsies using the root operation Extraction (pulling or stripping out or off all or a portion of a body part by the use of force). Again, we will use the seventh character X to denote this is a biopsy.
The ICD-10-PCS Alphabetic Index will be a big help when it comes to coding biopsies. If you look up biopsy in the index, it directs you to:
  • See Drainage with qualifier Diagnostic
  • See Excision with qualifier Diagnostic
  • Bone Marrow, see Extraction with qualifier Diagnostic
Coding Clinic, Fourth Quarter 2013, p. 111, also addresses the root operation for a bone marrow biopsy.
This article originally appeared on HCPro’s ICD-10 Trainer blog.

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