ICD-10-PCS root operations, the Definitional Lameness Scale, and the One Ring

Way back in the early days of ICD-10-PCS development, “root operation” was defined as “the objective of the procedure.” As definitions go, “the objective of the procedure” is about a seven on the Definitional Lameness Scale (DLS)—ten being “worse than useless” and one being “everything you ever wanted to know and then some.” I give myself permission to rate PCS definitions, because I was, among other things, Assistant Wordsmith Second Class on the PCS development team. And I happen to know that the definition of root operation as “the objective of the procedure” is intentionally a non-definition type definition.

Why? Because the 31 individual root operations each have their own definition. While still pretty general, all of the PCS root operation definitions, from Alteration and Bypass all the way to Transplantation, get a better rating on the DLS.  If we had a nice, tight definition of what a root operation is, it would compete directly with the individual definitions and then we would have all that malarkey about who is more powerful. To put it in “Lord of the Rings” terms, forging the “One Definition to Rule them All” would have been risky, if not downright evil. Sauron and his minions did it and look what a mess that caused.

Unfortunately, this less-than-perfect definition of what a root operation is causes a lot of brain calories to be expended discussing the Objective of the Procedure—which sometimes morphs into the Intent of the Procedure—rather than focusing on the operative report itself. Both “objective” and “intent” are the kind of words that say, “Hello! Welcome! Interpret me, please!” Even worse, “intent” makes it sound like coders are supposed to read the physician’s mind—usually not a good idea.

This kind of overthinking vis a vis the “objective of the procedure” can tempt coders to give precedence to the objective/intent of the procedure over choosing the key physical action(s) that best represents the work performed during the procedure.

Here’s a simplified example to illustrate the point: Imagine you are reading an operative report for a patient who has metastatic ovarian cancer, with tumors in the peritoneal cavity that are causing bowel obstruction. The surgeon describes extensive tumor debulking, and also describes “mobilizing” and “running” various portions of the bowel multiple times during the debulking procedure. At the end of the procedure he notes that the bowel lies in a more normal orientation, with resolution of the obstruction.

Is this a separate reposition procedure? Nope, and don’t let the inner philosophy major tell you otherwise. The fact that the bowel is back in its normal anatomical position and the obstruction is resolved after tumor debulking is the result of the tumor debulking and not a separate procedure. It is impossible to do the tumor removal without mobilizing and running the bowel—not to mention putting the bowel back where you found it. In this case, no separate procedure was performed to reposition the bowel, and so the only root operation performed in this case is Excision.

But wait, the inner philosophy major will say: "What about that diagnosis of bowel obstruction?” It must mean something. It’s right there at the top of the operative report—PREOPERATIVE DIAGNOSIS: 1. Peritoneal metastasis from ovary 2. Bowel obstruction. PROCEDURES PERFORMED: Tumor debulking of peritoneal metastasis and 2. Resolution of bowel obstruction. Doesn’t that mean there was a separate objective, to resolve the bowel obstruction?

Whose objective are we talking about, the objective of the surgeon? Well sure, the surgeon has two hoped for results—to remove tumors, and to relieve the patient’s bowel obstruction. Those “objectives” reside in the mind. In the physical world, only one procedure was performed to achieve those results. Put another way, the diagnosis can be thought of as the why, and the procedure as the how. There were two reasons (why) the patient was in surgery, but only one key physical action was performed (how).

Thinking that the objective/intent of the procedure possesses some special conceptual power that rules over the physical world has the appeal of the mysterious. Maybe, like in “Lord of the Rings,” if we hold these words next to the fire of our minds some special lingo appears and coding becomes…a quest! But no—sorry, “objective” and “intent” are just ordinary, fairly lame, words. My advice is…let the mystery be. Try not to overthink the objective of the procedure. If you want to keep your inner philosophy major quiet so you can get some work done, stick to the fundamentals: Read the operative report with an eye to the key physical thing that was done to the patient. If multiple key physical things were done, they are mutually exclusive according to the root operation definitions, and no other coding instructions apply, then multiple codes are assigned.

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

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