When it comes to utilization of ICD 10 codes for surgical and medical procedures, most of the codes are added in the inpatient setting of the hospital. Regarding the codes given in OCD 10 totally 7 characters are in the medical procedures for surgical processes and each character denotes the aspect of the procedures particularly. The root operation of the surgical procedure is denoted by the third character of the code.
Totally 31 root operations have been given in surgical and medical section of ICD 10 codes and they are arranged in groups.
- Root operations in which all or some of a body part is taken out
- Root operations in which gasses or fluids or solid is taken out from a body part
- Root operations in which only cutting and separation
- Root operations in which all or some of a body part is put back or put in or move out or move in
- Root operations in which tubular body part is altered in terms of diameter
- Root operations in which a device is used.
- Root operations in which repairs are involved
- Root operations in which other objectives are included.
Multiple codes are used when multiple procedures are carried out. The fact is that anastomosis is not included in root operation because it is not a surgery procedure but joining procedure. This is a part of another procedure called as resection or bypass. Incision is also not included in the root term because it is also another procedure and it means opening and not surgical.
Root operations in which all or some of a body part is taken out
When the a portion of a body part is cut off or cut out of without any replacement by using sharp instrument then excision is used. Most of the root operations involve sharp instruments.
- Bone saw
- Electrocautery tip
Diagnostic is a qualifier that is available to find the procedures of excision and it includes biopsies. The examples of excision are: liver biopsy, partial nephrectomy, excision of cyst, breast lumpectomy, excision of melanoma or sigmoid polypectomy.
When it comes to endometrial and bone marrow they are not coded in terms of excision. But they are coded in terms of extraction in the root operations along with qualifier diagnostic which is used to find the biopsy.
Resection is alike excision but in resection the cutting off or cutting out is done without any kind of replacement of any body part. It is included in ICD 10 and the examples of resection are: prostatectomy, lobectomy of lung nephrectomy, resection cecum and total mastectomy. For instance, the right upper lung lobectomy is coded to upper lung lobe resection
For instance, the coding of right upper lung lobectomy is done to resection of upper lung lobe and not as excision of lung. Check the codes of root operations completely to get better idea on it.