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EDITOR’S NOTE: During a recent Talk Ten Tuesdays, Candice, a listener, asked Erica Remer, MD a question about pyloromyotomy root operation. Dr. Remer’s response appears below.

Paraphrased, the question posed centered on the notion that references previously recommended using dilation as a root operation because the intent of pyloromyotomy is to “open up.” Candice wondered if the third quarter Coding Clinic got it wrong on pages 23 and 24. I don’t think so.

There are various pathologies that can result in the constriction or restriction of blood flow through a body part. If a tubular structure is too narrow, we may need to, as Candice said, “open it up.” If we insert an instrument that just expands the tubular structure, this is dilation. The definition in the guidelines is “expanding an orifice or the lumen of a tubular body part.” Balloon angioplasty, stenting, and esophageal dilation with progressive dilators are examples of the “dilation” root operation. The intent is to expand, or dilate, the luminal space.

Pyloric stenosis involves a different pathology. The pylorus is the opening between the stomach and the duodenum, created by the pyloric sphincter, an annular, or encircling, muscle. If the muscle hypertrophies or overgrows, the luminal opening is reduced, causing obstruction. The treatment is to incise the pyloric longitudinal and circular muscle fibers, thereby alleviating the constriction. The muscle fibers are divided, therefore, this is an example of the root operation “division,” defined as “cutting into a body part without draining fluids and/or gases from the body part, in order to separate or transect a body part.” The intent is to divide the constricted muscle.

The last root operation I will mention is release. Imagine a partial bowel obstruction from adhesions. When the surgeon performs an adhesiolysis relieving the constriction, he is performing a release: “freeing a body part from an abnormal physical constraint by cutting or by use of force.” The intent is to release the abnormally constricted body part of its constriction.

In all of these cases, the intent is to “open up” the constricted body part. The root operation is selected according to the technique that actually accomplished the goal. Don’t confuse the “operation” with the “root operation.”

When you are trying to unravel what the surgeon did so you can code in ICD-10-PCS, think about how the outcome was achieved. A debridement could be an excision or an extraction, depending on certain factors.

The goal of opening up an orifice may be accomplished by dilation, division, or release. Whatever it takes, code that.

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Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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