ICD-10: Root Operations with other objectives: alteration, creation, fusion by Dr. Helen Walker

Feb 13 2012 3:07 PM

Root Operation 0: Alteration

The purpose of an Alteration procedure is to improve appearance..

Examples include: Face lift, Breast augmentation, cosmetic rhinoplasty, tummy tucks and liposuction of thighs.

Coding Example: Cosmetic blepharoplasty

Character 1 Section	Character 2 Body System	Character 3 Root Operation	Character 4 Body Part	Character 5 Approach	Character 6 Device	Character 7 Qualifier
MEDICAL & SURGICAL	EYE	ALTERATION	UPPER EYELID LEFT	OPEN	NO DEVICE	NO QUALIFIER
0	8	0	P	0	Z	Z

Root Operation 4: Creation

Sex change operations are the only procedures coded under Creation procedures. These are defined as: Making a new genital structure that does not take over the function of a body part. Examples include: Creation of vagina in a male or Creation of penis in a female

Coding Example: Creating a vagina in a male patient using autograft

Character 1 Section	Character 2 Body System	Character 3 Root Operation	Character 4 Body Part	Character 5 Approach	Character 6 Device	Character 7 Qualifier
MEDICAL & SURGICAL	ANATOMICAL REGIONS, GEN	CREATION	PERINEUM, MALE	OPEN	AUTOLOG TISSUE SUBST	VAGINA
0	W	4	M	0	7	0

Root Operation G: Fusion

Fusion procedures are performed only on joints and involve joining together portions of an articular body part rendering the body part immobile. Fixation devices, bone grafts or other means can fuse joints together.

Examples include: Spinal fusion, radiocarpal fusion, intercarpal fusion, and ankle arthrodesis

Coding Example: Anterior cervical fusion C-2 through C-4 with bone bank graft

Character 1 Section	Character 2 Body System	Character 3 Root Operation	Character 4 Body Part	Character 5 Approach	Character 6 Device	Character 7 Qualifier
MEDICAL & SURGICAL	UPPER JOINTS	FUSION	CERVICAL JT 2 OR MORE	OPEN	NONAUTOLOG TISSUE SUBST	ANT APPROACH ANT COLUMN
0	R	G	2	0	K	0

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