Title: Examination, Other Repairs, Other Operations
Course: Intermediate Coding and Classification Systems > Section: Module 5: Examination, Other Repairs, Other Objectives

Introduction

Now onto Chapters 6 and 7! In these two chapters you will learn about root operations that Involve Examination only, Other Repairs, or Other Objectives. There are seven root operations in this section from very specific to very general in nature. Again, the coding guidelines are addressed for each one with examples to help you understand what the focus of the procedures is describing.

Inspection of a body part performed in order to achieve the objective of a procedure is not coded separately. Example: A fiber-optic bronchoscopy is performed to irrigate the bronchus, only the Irrigation procedure is coded. Inspection involves looking at rather than doing something to a body part.

Repair is the “NEC” or Not Elsewhere Classified root operation and only used if the objective of the procedure is not described in any other root operation.

The key to coding in ICD-10-PCS is learning the root operations and Approaches. In addition, the anatomical regions, systems and individual anatomy of the body systems are important. Therefore, the next chapters will focus on these areas and then broken out into each body system refreshing your anatomy.

Chapter 7 discusses anatomical regions and states that when procedures are performed on individual body parts, those procedures are coded based on the root operation performed on the specific body part within the specific body system, not the anatomical region.

Course Outcomes

- Describes the basic coding steps for coding medical procedures in both ICD-9-CM and ICD-10-PCS. (1)
- Interprets the basic coding guidelines established by the American Hospital Association for both ICD-9-CM and ICD-10-PCS. (2)
- Converts medical documentation into both ICD-9-CM and ICD-10-PCS codes. (3)
- Applies the official coding guidelines to the coding of medical procedures for all body systems (circulatory, respiratory, musculoskeletal, urinary, blood organs, reproductive, gastrointestinal, etc.) (4)
- Compares and contrasts the differences between the ICD-9-CM and ICD-10-PCS classification systems. (8)

Objectives

Upon completion of this module you should be able to:

- List the root operations in the grouping that involve examination only.
- State the definitions of the root operations Inspection and Map.
- Describe the guidelines applicable for coding Inspections of overlapping layers of the musculoskeletal system and multiple tubular body parts
- Identify the correct coding for procedures that are discontinued before any other root operation can be performed.
- Discuss the coding of Inspection along with another root operation performed on the same body part using a different approach.
- List the two body systems that include the root operation Map.
- Identify the three body systems that are applicable to Control procedures.
- List the seven definitive root operations that should be coded as applicable for Control procedures that are initially unsuccessful and converted to one of these root operations.
- Describe the root operation Repair and its use as the NEC root operation.
- Identify the three body systems that are applicable to Fusion procedures.
- Indicate the device value used for Fusion procedures that include a combination of devices.
- Describe the use of the Alteration root operation versus other root operations in the Medical and Surgical section.
- Discuss the use of the Creation codes for gender reassignment or sex change operations
- Discuss the three anatomical body system values in ICD-10-PCS, General, Upper Extremities and Lower Extremities.
- Identify the area that divides the upper and lower extremities.
- Discuss the components of the Upper and Lower Extremity region in relation to Detachment and Reattachment procedures.
- Describe the use of the root operation Control in the Anatomical Regions body systems.
- Discuss the other applicable root operations for general regions and the upper and lower extremities, including Detachment, Division, Alteration and Creation.
- List the six applicable approaches used in the anatomical regions general, and the four applicable approaches for the upper and lower extremities regions.
- Recognize the applicable device values for the anatomical regions.
- Discuss the use of qualifier values for Bypass in the general regions and Detachment in the upper and lower extremities regions.

Readings & Resources

- Chapters 6 and 7
- Complete all exercises and check your answers
- Review Coding Guidelines on root operations
- Read Coding Tips

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