Understanding ICD-10 data: What the root operations can (and can’t) tell you

In my last blog I said that the ICD-10-PCS root operations are not created equal—some are narrowly defined, and some have “wiggle room” in their definitions. By “narrowly defined,” I mean root operation definitions that as coded data correlate with one or two generally similar kinds of procedures, and by “wiggle room,” I mean root operations that as coded data include a mixed bag of different kinds of procedures. The phrase “as coded data” refers to downstream review processes where the data is being analyzed to see how a provider is doing in areas such as clinical documentation, quality, case mix—areas in which the data being analyzed may be distilled into numbers or percentages, but still allows one to trace back to individual codes.

An example of a narrowly defined root operation is Bypass. The objective of Bypass as defined in ICD-10-PCS is to “alter the route of passage of the contents of a tubular body part,” and is achieved by “rerouting the contents [of the body part] to a downstream area” using “one or more anastomoses.” In the world of coded data this matches up with procedures that providers typically call a bypass, such as:

• CABG (coronary artery bypass graft)
• Fem-pop bypass (bypass from the femoral to the popliteal artery in the leg)

Root operation Bypass also includes surgical procedures to create an “ostomy” of some sort—for example, a colostomy surgically creates an opening in the abdominal wall that reroutes the digestive waste out through that new opening. Since there are just a couple of kinds of procedures that are coded to the root operation Bypass, it is pretty straightforward to analyze the use of such codes.

Whether a root operation is narrowly defined or has wiggle room affects how clearly it can be understood as coded data. Reviewing a hospital stay for medical necessity, for example, the narrowly defined root operations are unambiguous as coded data. There should be a clear correlation between a procedure code classified to the root operation Bypass and the diagnosis code(s) that explain why that procedure was performed.

Root operations with wiggle room in their definitions require a bit more care. Repair is an example of a root operation that has a lot of wiggle room. As it says in the explanation following the root operation definition, Repair is to be used when any of the other root operations do not apply. So it can potentially include something as simple as the suturing of a body part, or something much more complex, such as:

• A palliative congenital cardiac procedure that cannot be coded any other way
• An unusual bypass for which the current PCS tables do not have a precise code
• A new surgical techniques not codeable using one of the other root operations

For this reason, reviewing a hospital stay containing root operation Repair codes requires a deeper understanding of ICD-10-PCS in order to reach valid conclusions about the coded data.

Root operation Inspection also has wiggle room, and can present a different kind of challenge. Although its definition is simple—“Visually and/or manually exploring a body part”—it can be used in two very different types of situations. In the first and most common type of situation, a planned diagnostic exploration of a body part is performed. For example, a patient with red blood in the stool has a colonoscopy performed—this is coded to root operation Inspection of the body part Large Intestine.

In a second, less common type of situation, a surgical procedure is ended before the intended surgical objective—or any other more specific root operation objective—can be performed. For example, a female patient with ovarian cancer and suspected metastasis in the abdominal cavity is scheduled for oophorectomy and possible additional excision of the tumor. But after performing the laparotomy, the surgeon discovers evidence of more widespread metastasis than diagnostic imaging could detect, and ends the operative episode without performing a more definitive procedure such as excision. The operative episode is coded as an open Inspection of the body part Peritoneal Cavity.

As coded data, there is ambiguity in the use of root operation Inspection, because it can mean either a planned diagnostic procedure or a procedure that was ended before the planned procedure was performed. In the ovarian cancer example, as coded data the Inspection code itself does not signal that in this case it was used to capture a discontinued procedure. Without understanding this possible use of an Inspection code, the code could be construed as an extra trip to the OR for an unnecessary diagnostic procedure in a patient with a known condition.

Data containing codes with wiggle room in the root operation can be tricky as coded data. This is one of many situations in which a deep understanding of coding produces more useful data analysis. The coding profession is gearing up to produce more people with this kind of deep understanding, as coders prepare to take on new roles in this changing HIM world.

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