Rooting Out ICD-10 Procedure Codes, Part 3

By Ann Barta, MSA, RHIA

Root Operations Involving Cutting or Separation Only

Editor’s note: This is the third of a nine part series discussing the nine root operation groupings.

The medical and surgical procedure section of ICD-10-PCS contains most, but not all, procedures typically coded and reported in the hospital inpatient setting. This article is the third in a series explaining ICD-10-PCS root operation groupings in this important and largest section of ICD-10-PCS.

There are 31 root operations in the medical and surgical procedure section of ICD-10-PCS. These root operations are arranged into nine groups that share similar attributes. This article will focus on one of these groups:

Root Operations Involving Cutting or Separation Only

This group of ICD-10-PCS includes the following root operations:

• Division
• Release

Division-Root Operation 8
Division is defined as cutting into a body part without draining fluids or gases from the body part in order to separate or transect the body part. During a division procedure either all or a portion of the body part can be separated into two or more portions.

The root operation division is coded when the objective of the procedure is to cut into, transect, or otherwise separate all or a portion of a body part. When the objective is to cut or separate the area around a body part, the attachments of a body part, or between subdivisions of a body part that are causing abnormal constraints, then release is the correct root operation.

Examples of division procedures include osteotomy, sacral rhizotomy, anal sphincterotomy, division of a tendon, and spinal cordotomy.

Release-Root Operation N
Release is defined as freeing a body part from an abnormal physical constraint by cutting or by use of force. During a release procedure some of the restraining tissue may be removed but none of the actual body part is removed or taken out.

The objective of procedures represented in the release root operation is to free a body part from abnormal constraint. Release procedures are coded to the body part being freed and not the tissue being manipulated or cut to free the body part. A release procedure can be performed on the area around a body part, on the attachments to a body part, or between subdivisions of a body part that are causing the abnormal constraint.

Examples of release procedures include carpal tunnel release, adhesiolysis, frenulotomy for treatment of tongue-tie syndrome, tendon release, and manual rupture of joint adhesions.

References
Centers for Medicare and Medicaid Services (CMS). “2010 ICD-10-PCS Code Tables and
Index.” Available online at www.cms.hhs.gov/ICD10.

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

CMS. “ICD-10-PCS Draft Coding Guidelines.” Appendix B in “2010 ICD-10-PCS Reference
Manual.” Available online at www.cms.hhs.gov/ICD10.

- Ann Barta is a professional practice resource specialist at AHIMA.