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Based on theory, it would seem that ICD-10-PCS root operations could be assigned correctly with relative ease; however, practical application sometimes intersects with coding scenarios that make one question the selection of the appropriate root operation.

Hands-on ICD-10-PCS practice continually reinforces that only with the practical application of theory can one truly learn.

We begin with theory by defining the objective of each of these root operations:

  • Replacement: 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
  • Removal: taking out or off a device from a body part
  • Revision: Correcting to the extent possible a portion of a malfunctioning device or the position of a displaced device

All three of these root operations always involve a device. In ICD-10-PCS, a device is defined as a material or appliance that remains in or on the body at the end of the procedure. A device will have a fixed location at the procedure site and it will always be physically possible to remove a device (but not always practical, as some devices will be more integrated with the body over time than others).

In a replacement procedure, the objective is to replace the body part or a portion of the body part. This seems pretty straightforward. A caveat to remember is that if the code for replacement is assigned, the replacement code also captures the removal of the body part being replaced, and as such the removal or excision of the body part is not coded separately. A joint replacement, a bone graft, and a free skin graft are examples of replacement procedures.

During a revision procedure, a malfunctioning or displaced device is corrected. A portion of the device may be removed and replaced in a revision procedure, but a revision procedure will never involve the entire device. If the entire device is redone, the original root operation being performed should be coded. Examples of a revision procedure include adjusting a pacemaker lead, repositioning a catheter, or replacing a portion of a previously placed joint prosthesis.

When a device is completely removed without replacing it, the root operation is removal. For example, the removal of a tracheostomy tube or feeding tube represents such a procedure. There is an exception to this rule that involves replacing a previously placed device. A removal procedure is coded for taking out a device that was used in a previous replacement procedure; in other words, a complete re-do. If the previously placed device is completely removed and replaced, both removal and replacement procedure codes would be assigned. By coding both procedures, the data is reported with the capacity to illustrate that the latter procedure is actually what is defined in ICD-9-CM as a revision. 

Next, let’s take a look at a practical application. Consider a total knee replacement, which consists of the replacing of all three components of the knee joint (the tibial, femoral, and patellar components). The first time the total joint is replaced with an orthopedic device, the procedure would be coded to replacement based on the definition of the ICD-10-PCS root operation of the same name. The removal of the native joint would not be coded separately because it is considered to be inherent to the process to replace the joint.

Subsequently, if the total joint malfunctions and all three components need to be replaced, a code for the removal of the synthetic substitute would be required along with a code for the new total joint replacement. The assignment of both codes would indicate that this was not the original joint replacement procedure. 

A revision would be coded (instead of a removal and replacement) if any portion or component of the orthopedic joint replacement device needs to be adjusted or repositioned without replacing. A revision also would be the root operation of choice if only one component of a total knee replacement needs to be replaced. For example, if a patient had a total knee replacement of all three components and only the patellar component device needed to be removed and replaced, this would be a revision, because it is not a complete redo of the total joint replacement (which consisted of all three components). Another caveat is this: if the patient originally had only a partial knee replacement (for example the patellar component) and subsequently the prosthetic patellar component needed to be replaced, this would be coded utilizing removal and replacement root operations, because it would be a complete re-do of the procedure due to the fact that it was the entire device that was affected. A revision procedure will never involve the entire device.

Hopefully, by reviewing these few simple case scenarios, one can identify the need to code cases and apply the definitions of the root operations accurately in order to become proficient in ICD-10-PCS.

Only in thinking through the theory and applying it to real cases will the concepts of ICD-10-PCS become useful.  

About the Author

Lisa Roat, RHIT, CCS, CCDS is manager of HIM services for Nuance Healthcare. She has more than 23 years of experience and expertise within the healthcare industry specializing in clinical documentation improvement, coding education, reimbursement methodologies and healthcare quality for hospitals.  She is an American Health Information Management (AHIMA)-Approved ICD-10 CM/PCS Trainer and Ambassador.  Lisa has worked extensively with the development of ICD-10 education and services for Nuance Healthcare.

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