Root Operations that involve examination of body parts and regions: Inspection and Map by Dr. Helen Walker

Root Operation J: Inspection

Inspection procedures involve examining a body part either visually or manually. Discontinued procedures are coded as an inspection when no other root operations were performed. Examples: diagnostic arthroscopy, exploratory laparotomy, diagnostic hysteroscopy, endoscopy of maxillary sinus, laparotomy with palpation of liver, colonoscopy, diagnostic cystoscopy, and digital rectal exam.Coding Example:

Diagnostic colposcopy with examination of cervix

Root Operation K: Map

The map procedure is defined as locating the route of passage of electrical impulses and or locating functional areas in a body part. This only applies to cardiac and cortical mapping; examples include cardiac mapping, mapping of basal ganglia, and brain mapping.

Coding Example: Cardiac mapping

Root Operations involving cutting or separation only

Root Operation 8: Division

Division involves cutting into a body part without draining fluids in order to separate or transect the body part.  Look in the Op Report for “division” and “..otomy” as in osteotomy, esophagotomy, rhizotomy”. Examples of division procedures include division of foot tendon, division of bundle of HIS, osteotomy of wrist bone, esophagotomy of EG junction, and sacral rhizotomy

Coding Example: Anal sphincterotomy

 Root Operation N: Release

Code an operation as a “Release” when a body part is freed from constraint but none of the body part is removed.  Look for the terms such as adhesiolysis, incision of scar, release, lysis, freeing of an organ, and rupture of adhesions. Incision of scar contracture, frenulotomy, coracoacromial ligament release, mitral valvulotmy for release of fused leaflets, tendon release, rupture of joint adhesions, and tarsal tunnel release.

Coding Example: Release of median nerve

Reference: CMS: “2010 ICD-10-PCS Reference Manual” Available online at www.cms.hhs.gov/ICD10