1. Medical and Surgical Section Root Operations Examples
Root operations define the specific goal, or objective of the procedure. Therefore, we’ll find action words like bypass, change, control, destruction, detachment, transfer, transplant, etc., and are specified in the third character position, as seen on this list. Each root operation has an exact definition located next to the term in the Table section of ICD-10-PCS. Let’s take a look at this section. Open the PCS document again, and lets look at the definitions hyperlink. At the bottom of the table of contents page you’ll see a hyperlink that will take you to the Definitions page.
As we’re still in the Medical & Surgical Procedures, you’ll see the definitions for the section we’re working in. You’ll also remember this is the third character position, so you’ll open the 0_3 “Medical & Surgical Operation” hyperlink.

2. Medical and Surgical Section Root Operation Principles
The root operation is coded according to the objective of the procedure actually performed
Discontinued or modified procedures coded to procedure actually performed
Composite terms (e.g., colonoscopy, sigmoidectomy) are not root operations
If the intended procedure is discontinued, code the procedure to the root operation performed. If a procedure is discontinued before any other root operation is performed, code the root operation Inspection of the body part or anatomical region inspected.
For Example: A planned aortic valve replacement procedure is discontinued after the initial thoracotomy and before any incision is made in the heart muscle, when the patient becomes hemodynamically unstable. This procedure is coded as an open Inspection of the mediastinum.

3. Root Operations That Take Out Some or All of a Body Part
Five root operations represent procedures for taking out or otherwise eradicating some or all of a body part. Let’s review Procedures that take out or eliminate all or a portion of a body part, beginning with Excision.

4. Excision – Root Operation “B”
According to the definitions, this is the definition for the root operation Excision meaning the “cutting out or off, without replacement, a portion of a body part.”

5. Excision
Excision is coded when a portion of a body part is cut out or off using a sharp instrument. All root operations that employ cutting to accomplish the objective allow the use of any sharp instrument, including but not limited to
Scalpel
Wire
Scissors
Bone saw
Electrocautery tip
Excision is coded when a portion of a body part is cut out or off using a sharp instrument and is represented by letter “B”. All root operations that employ cutting to accomplish the objective allow the use of any sharp instrument, including but not limited to a scalpel, wire, scissors, a bone saw or an Electrocautery tip.

6. Additional Examples of Excision
Excision sebaceous cyst right buttock
Excision malignant melanoma from skin right ear
Laparoscopy with excision of endometrial implant from left ovary
EGD with gastric biopsy
Laparoscopic vertical sleeve Gastrectomy
Excision of basal cell carcinoma of lower lip
Open excision of tail of pancreas
Percutaneous biopsy of right gastrocnemius muscle
Open excision of lesion from right Achilles tendon
Here are some examples of procedures with the root operation of Excision.

7. Please insert YouTube videos of Excision examples from slides

8. Coding Note Excision – Root Operation B
Bone Marrow and Endometrial Biopsies
Bone marrow and endometrial biopsies are not coded to Excision. T
They are coded to Extraction, with the qualifier Diagnostic.
The coder must be careful to not misclassify procedures that may appear to possibly fall under one root operation, but actually are another. For Example, Bone Marrow and Endometrial Biopsies – Bone marrow and endometrial biopsies are not coded to Excision. They are coded to Extraction, with the qualifier Diagnostic.

9. Resection – Root Operation T
Here is the definition for the root operation Resection. “Cutting out or off, without replacement all of a body part.”
Resection is similar to Excision except Resection includes all of a body part, or any subdivision of a body part that has its own body part value in ICD-10-PCS, while Excision includes only a portion of a body part.

10. Additional Examples of Resection
Right hemicolectomy
Open resection of cecum
Total excision of pituitary gland
Explantation of left failed kidney
Open left axillary total lymphadenectomy
Laparoscopic-assisted total vaginal hysterectomy
Open resection of papillary muscle
Radical open retropubic prostatectomy
Laparoscopic cholecystectomy
Endoscopic bilateral total maxillary sinusectomy
Here we have examples of procedures which would be coded with the root word of Resection.

11. Coding Note Resection– Root Operation T
Lymph Nodes—
When an entire lymph node chain is cut out, the appropriate root operation is Resection. When a lymph node(s) is cut out, the root operation is Excision.
The coder must be careful to not misclassify procedures that may appear to possibly fall under one root operation, but actually are another. For example When an entire lymph node chain is cut out, the appropriate root operation is Resection. When a lymph node(s) is cut out, the root operation is Excision.
There is an opportunity to provide physician education on the need for more complete documentation in the medical record on the following:
Lymph node(s) versus the complete chain
The complete body part removal versus a portion

12. Detachment – Root Operation 6
Our next definition is Detachment, meaning “cutting off all or part of the upper or lower extremities.”

13. Detachment
Detachment represents a narrow range of procedures; it is used exclusively for amputation procedures. Detachment procedure codes are found only in body systems:
X, Anatomical Regions,
Upper Extremities
Y, Anatomic Regions, Lower Extremities
Because amputations are performed on extremities across overlapping body layers and so could not be coded to a specific musculoskeletal body system such as Bones or Joints
Detachment represents a narrow range of procedures as it is used exclusively for amputation procedures. Detachment procedure codes are found only in body systems:
X, Anatomical Regions;
Upper Extremities; or
Y, Anatomic Regions, Lower Extremities
Because amputations are performed on extremities across overlapping body layers, therefore, amputations could not be coded to a specific musculoskeletal body system such as Bones or Joints.

14. Additional Examples of Detachment
Fifth toe ray amputation
Fifth ray carpometacarpal joint amputation of left hand
Right leg and hip amputation through ischium
DIP joint amputation of right thumb
Right wrist joint amputation
Mid-shaft amputation of right humerus
Left fourth toe amputation at mid-proximal phalanx
Right above-knee amputation of distal femur
Here we see examples of procedures that would be coded to the root operation of Detachment.

15. Insert YouTube Video
Please insert YouTube videos of Excision examples from Detachment
Below Knee Amputation

16. Coding Note Detachment– Root Operation 6
Detachment Qualifiers –
The specific qualifiers used for Detachment are dependent on the body part value in the upper and lower extremities body systems.
There is an opportunity to provide physician education on the need for more complete documentation in the medical record on the following:
According to the definition, the coding professional needs to know if the amputation is at the proximal middle, or distal portion of the shaft of the humerus, femur, radius/ulna, or tibia/fibula. When a surgeon uses the word “toe” to describe the amputation, but the operative report says he extends the amputation to the midshaft of the fifth metatarsal, which is the foot, the qualifier is Partial 5th Ray

17. Destruction – Root Operation 5
The next root operation is Destruction (5) meaning the “physical eradication of all or a portion of a body part by the direct use of energy, force or destructive agent.”
Destruction “takes out” a body part in the sense that it obliterates the body part so it is no longer there. The term Destruction defines a broad range of common procedures, since it can be used anywhere in the body to treat a variety of conditions, including skin and genital warts, nasal and colon polyps, esophageal varices, endometrial implants and nerve lesions.

18. Additional Examples of Destruction
Radiofrequency coagulation of trigeminal nerve
Percutaneous radiofrequency ablation of right vocal cord lesion
Cautery of nosebleed
Cautery of oozing varicose vein of left calf
Laparoscopy with destruction of endometriosis on both ovaries
Laser percutaneous coagulation of right retinal vessel hemorrhage
Talc injection pleurodesis, left side
Sclerotherapy of brachial plexus lesion with alcohol injection
Fulguration of endometrium
Here are additional examples of procedures using the root operation Destruction.

19. Coding Note Destruction– Root Operation 5
Usually there is no pathology report present for Destruction procedures because the body part destroyed or obliterated. Occasionally, tissue remains in an instrument, and may be sent to pathology.
Coding Note: Usually there is no pathology report present for Destruction procedures because the body part is destroyed or obliterated. Occasionally, tissue remains in an instrument, and may be sent to pathology.

20. Extraction – Root Operation D
Extraction, root operation D is defined as “pulling or stripping out or off all or a portion of a body part by the use of force.”
Extraction is coded when the method employed to take out the body part is pulling or stripping. Minor cutting, such as that used in vein stripping procedures, is included in Extraction if the objective of the procedure is nevertheless met by pulling or stripping. As with all applicable ICD-10-PCS codes, cutting used to reach the procedure site is specified in the approach value.

21. Additional Examples of Extraction
Extraction of teeth
Suction dilation & curettage
Removal left thumbnail
Phacoemulsification cataract without replacement—with IOL is Replacement
Laparoscopy with needle aspiration of ova for in-vitro fertilization
Non-excisional debridement of skin ulcer, right foot-excisional is Excision
Here are several examples of procedures using the root operation of Extraction.

22. Additional Examples of Extraction
Open stripping of abdominal fascia, right side
Hysteroscopy with D&C
Liposuction for medical purposes, left upper arm—cosmetic is Alteration
Removal of tattered right ear drum fragments with tweezers
Microincisional phlebectomy of spider veins, right lower leg
Bone marrow biopsy
Endometrial biopsy (See note in Excision section.)

23. Coding Note Extraction– Root Operation D
The cervical canal is widened with a metal rod, and then the curette is passed. A curette is described as an instrument with a metal loop on the end of a long, thin handle, or spoon shaped with sharp edges. This curette gently scrapes the endometrium.
When coding a D&C in ICD-10-PCS, the Dilation is not separately coded because procedural steps necessary to reach the operative site and close the operative site are not coded separately (Coding Guideline B3.1b).

24. Coding Note Extraction– Root Operation D
During a liposuction, a small incision is made in the skin and a suction tube with a sharp end is inserted into the fat pockets. The instrument has been described as a long, thin, hallow shaft ending in a small, sharp-edged spoon. This is swept through the area between the skin layers and the deeper subcutaneous tissue, and then the vacuum pump suctions it out.
In a vein stripping, two small incisions are made—one above and one below the specified vein. These incisions are included in the Extraction root operation (see definitions above). A thin, flexible plastic wire is then threaded into the vein (at the top part) and guided toward the other cut. The vein is pulled out when the wire is pulled out through the lower cut. Hooks may also be used in the procedure.
Visit Medline Plus at the US National Library of Medicine National Institutes of Health to get information on these and other surgical procedures. Many excellent videos and tutorials are available.
During a liposuction, a small incision is made in the skin and a suction tube with a sharp end is inserted into the fat pockets. The instrument has been described as a long, thin, hallow shaft ending in a small, sharp-edged spoon. This is swept through the area between the skin layers and the deeper subcutaneous tissue, and then the vacuum pump suctions it out.
In a vein stripping, two small incisions are made—one above and one below the specified vein. These incisions are included in the Extraction root operation (see definitions above). A thin, flexible plastic wire is then threaded into the vein (at the top part) and guided toward the other cut. The vein is pulled out when the wire is pulled out through the lower cut. Hooks may also be used in the procedure.
Visit MedlinePlus at the US National Library of Medicine National Institutes of Health to get information on these and other surgical procedures. Many excellent videos and tutorials are available.

25. Coding Note Extraction– Root Operation D
Be careful of documentation.
It is important to convert common terminology to the appropriate root operation according to the intent of the procedure.
For example, the procedure documentation may say “removal,” but in actuality, using PCS definitions, an extraction was performed. Removal of a thumbnail would be coded to Extraction.
The root operation of Removal is not correct because by definition a Removal in ICD-10-PCS is defined as taking out or off a device from a body part.
Be careful of documentation. It is important to convert common terminology to the appropriate root operation according to the intent of the procedure.
For example, the procedure documentation may say “removal,” but in actuality, using PCS definitions, an “extraction” was performed. For example, removal of a thumbnail would be coded to Extraction. The root operation of Removal is not correct because by definition a Removal in ICD-10-PCS is defined as taking out or off a device from a body part.

26. Reattachment – Root M Reattachment M 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 reestablished
Examples
Reattachment of hand, reattachment of avulsed kidney, reattachment of finger
The root operation Reattachment (M) is defined as “putting back in or on all or a portion of a separated body part to its normal location or other suitable location.”
Procedures coded to Reattachment include putting back a body part that has been cut off or avulsed. Nerves and blood vessels may or may not be reconnected in a Reattachment procedure.

27. Additional Examples of Reattachment
Here are examples that would be coded to Reattachment.

28. Place Holder
Please insert YouTube videos
Finger reattachment surgery

29. Transfer – Root Operation X
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
Our next root operation is Transfer (X) which is defined as “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.”
The root operation Transfer is used to represent procedures where a body part is moved to another location without disrupting its vascular and nervous supply. In the body systems that classify the subcutaneous tissue, fascia and muscle body parts, qualifiers can be used to specify when more than one tissue layer was used in the transfer procedure, such as a musculocutaneous flap transfer.

30. Here is another coding note for Body system value:
The body system value describes the deepest tissue layer in the flap. The qualifier can be used to describe the other tissue layers, if any, being transferred.

31. Additional Examples of Transfer
Here are additional examples of procedures that would use the root operation Transfer.

32. Reposition – Root Operation S
Root operation Reposition (S) is defined as “moving to its normal location or other suitable location all or a portion of a body part.”
Reposition represents procedures for moving a body part to a new location. The range of Reposition procedures includes moving a body part to its normal location, or moving a body part to a new location to enhance its ability to function.

33. Coding Note: The diagnosis code in ICD-10-CM would reflect that a displaced fracture is being reduced when the root operation of Reposition is used.
Here is another Coding Note: The diagnosis code in ICD-10-CM would reflect that a displaced fracture is being reduced when the root operation of Reposition is used.

34. Additional Examples of Reposition
Open fracture reduction with internal fixation, left tibia and ulna
Open fracture reduction, displaced fracture of right distal humerus
Closed reduction with percutaneous internal fixation of left femoral neck fracture
Right knee arthroscopy with reposition of patellar ligament
Open transposition of ulnar nerve
Laparoscopy with gastropexy for malrotation
Here are examples of procedures that would be coded to Reposition.

35. Place Holder Please insert YouTube videos
Anterior Transposition of the ulnar nerve
Laparoscopic Ladd surgery for intestinal Malrotation

36. Activity Coding Removal
Coding Case:
Removal of external fixator, left humeral head fracture
There would be one code in this case
Let’s open the PCS_2013 Tables and Index file, that you downloaded from Lesson 1
On the first page, Under “Tables of Contents” and click on the hyperlink “0” Medical Surgical (This should bring you to the “Medical Surgical" section on page 2.) This is the 1st Character for our code “0”. The Medical Surgical Section
We now need to select the 2nd Character which is “Body System”. Based on our understanding of A&P we know that for this case the body system is “Upper Bones” Click on “OP” Which will bring you to the “Upper Bones” section of the Body System
We now need to select the 3rd Character which is “Root Operation”. Based on the case we read that “Removal of external fixator” so we will select “Removal” which is “OPP
We are now on our “Table” and have our first three characters
The next character “Body Part” D” would be the correct character which describes “Humeral Head, Left”
The next character “Approach” would be “X” “External”.
The next character “Device” would be “5” for “External Fixation Device”
The next character “Qualifier” would be “Z” for “No Qualifier”

37. Coding Case- Removal 0PPDX5Z
Section
Medical and Surgical
Body System
Upper Bones P
Root
Removal
Body Part
Humeral Head, Left D
Approach
External X
Device
External Fixation Device 5
Qualifier
No Qualifier Z
Index: Removal of device from
There is no other documentation that this was done open, percutaneous, or percutaneous endoscopic. The approach is coded to External in this case, but certainly the documentation in the actual medical record would decide the approach value.

38. Activity Coding Inspection
Coding Case:
Diagnostic bronchoscopy of the left bronchus
There would be one code in this case
Let’s open the PCS_2013 Tables and Index file, that you downloaded from Lesson 1
On the first page, Under “Tables of Contents” and click on the hyperlink “0” Medical Surgical (This should bring you to the “Medical Surgical" section on page 2.) This is the 1st Character for our code “0”. The Medical Surgical Section
We now need to select the 2nd Character which is “Body System”. Based on our understanding of A&P we know that for this case the body system is “Respiratory System” Click on “OB” Which will bring you to the “Respiratory System” section of the Body System
We now need to select the 3rd Character which is “Root Operation”. Based on the case we read that “Diagnostic bronchoscopy of the left bronchus ” so we will select “Inspection ” which is “OBJ”
We are now on our “Table” and have our first three characters
The next character “Body Part” 0” would be the correct character which describes “Tracheobronchial Tree”
The next character “Approach” would be “8” “Via Natural or Artificial Opening Endoscopic”.
The next character “Device” would be “Z” for “No Device”
The next character “Qualifier” would be “Z” for “No Qualifier”

39. Coding Case- Inspection 0BJ08ZZ
Section
Medical and Surgical
Body System
Respiratory B
Root
Inspection J
Body Part
Tracheobronchial Tree
Approach
Via Natural or Artificial Opening Endoscopic 8
Device
No Device Z
Qualifier
No Qualifier
Index: Inspection, tracheobronchial tree, or Bronchoscopy (0BJ08ZZ).
Coding Guideline B3.11b states if multiple tubular body parts are inspected, the most distal body part inspected is coded. If multiple non-tubular body parts in a region are inspected, the body part that specifies the entire area inspected is coded. The trachea and bronchus are tubular body parts, so the bronchus would be the most distal. In PCS, the body part is Tracheobronchial Tree, and left and right are not differentiated.

40. Activity Coding: Control
Coding Case:
Open exploration and ligation of post-op arterial bleeder, right upper arm
There would be one code in this case
Let’s open the PCS_2013 Tables and Index file, that you downloaded from Lesson 1
On the first page, Under “Tables of Contents” and click on the hyperlink “0” Medical Surgical (This should bring you to the “Medical Surgical" section on page 2.) This is the 1st Character for our code “0”. The Medical Surgical Section
We now need to select the 2nd Character which is “Body System”. Based on our understanding of A&P we know that for this case the body system is “Anatomical Regions, Upper Extremities” Click on “OX” Which will bring you to the “Anatomical Regions, Upper Extremities” section of the Body System
We now need to select the 3rd Character which is “Root Operation”. Based on the case we read that “Open exploration and ligation of post-op arterial bleeder, ” so we will select “Control” which is “OX3”
We are now on our “Table” and have our first three characters
The next character “Body Part” 8” would be the correct character which describes “Upper Arm, Right”
The next character “Approach” would be “0” “Open”
The next character “Device” would be “Z” for “No Device”
The next character “Qualifier” would be “Z” for “No Qualifier”

41. Coding Case- Control 0X380ZZ
Index: Ligation – see Occlusion. Exploration – see Inspection.
Both of these indicate a different procedure. To code this case correctly, one needs to understand the intent/definition of Control – stopping, or attempting to stop, postprocedural bleeding

42. Coding Case- Rationale
Control is the correct root operation here because Occlusion (ligation) is not one of the root operations listed in Coding Guideline B3.7 that would send a control of Postprocedural bleeding to a different root operation (Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection).
Under Control, note that the only appropriate body systems are Anatomical Regions, General (0W3), Anatomical Regions, Lower Extremities (0Y3), and Anatomical Regions, Upper Extremities (0X3).

43. Activity: Coding Fusion
Coding Case:
Posterior spinal fusion of the anterior column at L2-L4 levels with BAK cage interbody fusion device, open
There would be one code in this case
Let’s open the PCS_2013 Tables and Index file, that you downloaded from Lesson 1
On the first page, Under “Tables of Contents” and click on the hyperlink “0” Medical Surgical (This should bring you to the “Medical Surgical" section on page 2.) This is the 1st Character for our code “0”. The Medical Surgical Section
We now need to select the 2nd Character which is “Body System”. Based on our understanding of A&P we know that for this case the body system is “Lower Joints” Click on “OS” Which will bring you to the “Lower Joints” section of the Body System
We now need to select the 3rd Character which is “Root Operation”. Based on the case we read that “Posterior spinal fusion of the anterior column at L2-L4 levels with BAK cage interbody fusion device,” so we will select “Fusion” which is “OSG”
We are now on our “Table” and have our first three characters
The next character “Body Part” 1” would be the correct character which describes “Lumbar Vertebral Joints, 2 or more”
The next character “Approach” would be “0” “Open”
The next character “Device” would be “A” for “Interbody Fusion Device”
The next character “Qualifier” would be “J” for “Posterior Approach, Anterior Column”

44. Coding Case- Fusion 0SG10AJ
Index: Fusion. Lumbar, 2 or more is selected because two joints are involved.

45. Coding Case- Rationale:
Coding Tip: Note that lumbar, lumbosacral, sacrococcygeal, coccygeal, and sacroiliac joints are listed in Lower Joints. Occipital-cervical, cervical, cervicothoracic, thoracic, and thoracolumbar vertebral joints are listed in Upper Joints.
The posterior lumbar interbody fusion (PLIF) provides a solid fusion in the treatment of spinal instability. Previously bone graft was used to provide the spacer, but loss of height was an outcome. New techniques have been developed, including the implantation of Bagby and Kuslich cages (BAK). These are utilized in both Anterior and Posterior approaches.

46. Activity Coding Repair
Coding Case:
Closure of skin laceration, left external ear
There would be one code in this case
Let’s open the PCS_2013 Tables and Index file, that you downloaded from Lesson 1
On the first page, Under “Tables of Contents” and click on the hyperlink “0” Medical Surgical (This should bring you to the “Medical Surgical" section on page 2.) This is the 1st Character for our code “0”. The Medical Surgical Section
We now need to select the 2nd Character which is “Body System”. Based on our understanding of A&P we know that for this case the body system is “Skin and Breast” Click on “OH” Which will bring you to the “Skin and Breast” section of the Body System
We now need to select the 3rd Character which is “Root Operation”. Based on the case we read that “Closure of skin laceration, left external ear, ” so we will select “Repair” which is “OHQ”
We are now on our “Table” and have our first three characters
The next character “Body Part” 3” would be the correct character which describes “Skin, Left Ear”
The next character “Approach” would be “X” “External”
The next character “Device” would be “Z” for “No Device”
The next character “Qualifier” would be “Z” for “No Qualifier”

47. Coding Case- Repair 0HQ3XZZ
Section
Medical and Surgical
Body System
Skin and Breast H
Root
Repair Q
Body Part
Skin, Left ear 3
Approach
External X
Device
No Device Z
Qualifier
No Qualifier
Index: Repair (The approach is Open, even though the surgical exposure may have been created by the wound itself. The chest wall is part of the Anatomical Regions, General body system.

48. Activity: Coding Creation
Coding Case:
Creation of penis in female patient using tissue bank donor graft
There would be one code in this case
Let’s open the PCS_2013 Tables and Index file, that you downloaded from Lesson 1
On the first page, Under “Tables of Contents” and click on the hyperlink “0” Medical Surgical (This should bring you to the “Medical Surgical" section on page 2.) This is the 1st Character for our code “0”. The Medical Surgical Section
We now need to select the 2nd Character which is “Body System”. Based on our understanding of A&P we know that for this case the body system is “Anatomical Regions, General” Click on “OW” Which will bring you to the “Anatomical Regions, General” section of the Body System
We now need to select the 3rd Character which is “Root Operation”. Based on the case we read that “Creation of penis in female patient ,” so we will select “Creation” which is “0W4”
We are now on our “Table” and have our first three characters
The next character “Body Part” N” would be the correct character which describes “Perineum, Female”
The next character “Approach” would be “0” “Open”
The next character “Device” would be “J” for “Synthetic Substitute”
The next character “Qualifier” would be “1” for “Penis”

49. Coding Case- Creation 0W4N0J1
Section
Medical and Surgical
Body System
Anatomical Regions, General W
Root
Creation 4
Body Part
Perineum, Female N
Approach
Open
Device
Synthetic Substitute J
Qualifier
Penis 1
Index: Creation.
Note that there is only one body system—Anatomical Regions, General (0W4) and only two body part values—Perineum, Female (0W4N) and Perineum, Male (0W4M) for this root operation.

50. The choices for device are autologous, synthetic substitute, or nonautologous tissue substitute. The definitions for each are listed here:
Type of Tissue
Device Character
Definition
Autologous (vein or artery)
9 or A
Referring to a graft in which the donor and recipient areas are in the same individual
Synthetic Substitute J
Any type of synthetic substitute
Nonautologous Tissue Substitute K
Nonautologous allogeneic donor tissue implanted from one human to another