ICD-10: What Control is not

Warning: This blog may be pretty heavy going for non-coders. Possible side effects include, but are not limited to, uncontrolled eye-rolling, heavy-sigh-induced hypoxemia, facial tics and persistent vegetative state. If symptoms persist for seven days, don’t say we didn’t warn you.

Thanks to Sue and Donna for their recent dialogue on the revised definition of root operation Control for the October 1, 2016 update. They did a first-rate job of introducing the expanded definition and examples. I’m going to talk a bit more about these new boundaries in the classification—why the definition was revised, and what is not included in the root operation Control.

First, the change. The root operation Control used to be defined as, “Stopping, or attempting to stop, postprocedural bleeding.” Now the definition says, “Stopping, or attempting to stop, postprocedural or other acute bleeding.”

The idea behind the revised definition is that the physical work to try to control bleeding is similar enough, regardless of the reason, that such procedures should all be cubbyholed in the same place. The original root op definition was easier to explain, but it is basically a diagnosis distinction, not a procedure distinction. Control of bleeding is control of bleeding regardless why it is done, and the people who proposed the change hope that opening up the definition a bit will improve data collection.

However, that little phrase “other acute” has apparently got coders rattled. Since the updated definition was posted, I have been asked 1) whether Control now includes trauma repairs, 2) whether it means that measures to achieve hemostasis for an intraoperative bleed are coded separately, and 3) whether the diagnosis has to match, i.e. it has to describe an acute condition. The answers are no, no, and no. But I don’t expect you to just be satisfied with a one-word answer, inquiring minds that you are, so let’s go through these “not Control” scenarios one by one.

Not for repair of traumatic laceration

The classic example of trauma repair is repair of laceration. Shakespeare made the point pretty memorably—if you prick us, we bleed (technically that’s a puncture wound, but this is the kind of quibble that drives everyone else crazy about coders). The fact that a body part bleeds when cut is a result of the trauma, and the fact that bleeding is controlled is a result of repairing the lacerated body part. Bleeding and control of bleeding are inevitable; they are byproducts of the whole trauma deal. Producing coded data focusing on the bleeding would miss the point.

The procedure to suture or otherwise repair a laceration is coded to the root operation Repair, because when wound edges are brought together it is the body part that is the focus of the procedure. A laceration of the shoulder muscle repaired in layers is coded to the root operation Repair and the body part is the upper arm muscle. Ditto nerve, ditto artery. What!?! Yep, you betcha, a laceration whose deepest extent is documented as a named blood vessel that requires surgical closure is coded to repair of that artery. Think suicide attempt by slashing the radial arteries in the wrist, think stab wound that nicks the subclavian artery. Those specific arteries will be the focus of the documentation and the procedure to repair them. Bottom line is that nothing has changed for coding repair of laceration.

Hemostasis not separately coded

I took too long with that last explanation, so I am heading straight down into the weeds here: imagine an abdominal surgery for metastatic ovarian cancer with lots of adhesions and peritoneal nodules. Some portion of the surgery is spent controlling multiple bleeding points. Control of bleeding in this type of scenario has never been separately coded, and that is still the case. Achieving hemostasis is a prerequisite to the successful conclusion of most surgical procedures, so it serves no practical purpose to code Control—in fact it would water down the data to code a separate procedure for control of bleeding in these circumstances.

Does not require an acute diagnosis

In addition to the revised definition itself, there are a few additional examples included in the definition of the root operation Control. They are: control of intracranial subdural hemorrhage, control of bleeding duodenal ulcer, control of retroperitoneal hemorrhage.

Notice that none of the additional examples use the word “acute” in the description. The focus is on the procedure, not the diagnosis. The revised definition is not intended to correlate in some rigid way with an “acute” diagnosis. The data from root operation Control is intended to capture separate procedures performed expressly for the purpose of controlling bleeding. Because a separate procedure to stop the bleeding is necessary or the patient will keep bleeding, the bleeding is acute regardless whether the diagnosis uses the word acute or not. A stroke from an intracranial bleed is an acute condition. Postprocedural bleeding is acute bleeding. Bleeding from cancer in the retroperitoneum, and other causes not explicitly in the new examples, is also acute bleeding.

Take the example of control of a bleeding duodenal ulcer. Notice the example does not specify that the ulcer was diagnosed as an acute ulcer or a chronic ulcer. A procedure to stop bleeding of an ulcer is coded to root op Control if the procedure is performed specifically to try to control the bleeding, and no more definitive procedure is done to that body part to repair the body part.

Remember, guideline B3.7 regarding Control vs. more definitive root operations is still in force. Here it is again, as a reminder.

The root operation Control is defined as, “Stopping, or attempting to stop, postprocedural or other acute bleeding.” If an attempt to stop postprocedural or other acute bleeding is initially unsuccessful, and to stop the bleeding requires performing any of the definitive root operations Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then that root operation is coded instead of Control.

Example: Resection of spleen to stop bleeding is coded to Resection instead of Control.

Don’t succumb to the temptation to turn coding into a word matching game that leaves your common sense in the dust without your being aware of it. Armed with the revised root operation definition, the existing guidelines, and your own common sense, defensible coding is… (lame pun alert) within your control.

Rhonda Butler is a clinical research manager with 3M Health Information Systems.