Coding Root Operations with ICD-10-PCS: Understanding Transplantation, Reattachment, Transfer, and Reposition

By Theresa Rihanek, MHA, RHIA, CCS

Editor's note: This is the fifth in a series of 10 articles discussing the 31 root operations of ICD-10-PCS.

In the Journal of AHIMA's continuing Coding Notes series focusing on the 31 root operations of ICD-10-PCS, this article will focus on the definitions of four root operations:

• Transplantation
• Reattachment
• Transfer
• Reposition

Root Operation Y: Transplantation

The definition for the Transplantation root operation provided in the 2014 ICD-10-PCS Reference Manual is "Putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part." The body part value represents the site of the transplantation. The qualifier value denotes the type of transplantation whether allogeneic, syngeneic, or zooplastic. In Transplantation procedures, the native body part may or may not be removed and the transplanted body part may take over all or part of the function of the transplanted organ.

Transplantation represents a small number of procedures in ICD-10-PCS. Some example procedures include a kidney transplant or heart transplant. Note that bone marrow, stem cell, and pancreatic islet cell transplants are not included in the Transplantation root operation. Rather, these are assigned using the root operation Administration.

Comparing ICD-9-CM and ICD-10-PCS: Transplantation

The following is an example of how ICD-9-CM and ICD-10-PCS compare in code assignment for Transplantation procedures.

Scenario: Kidney Transplant

The right kidney was transplanted using a live non-related donor kidney. A curvilinear incision in the right groin was made dissecting into the retroperitoneum through the transverse abdominis muscle. The patient's native kidney was left in place. The donor kidney was sutured into place and perfusing well at the close of the procedure.

In ICD-9-CM, the Alphabetic Index main term entry is Transplant, Transplantation; subterm Kidney, NEC identifies code 55.69, Other kidney transplantation. An additional code is assigned to identify the source of the donor kidney, 00.92, Transplant from live non-related donor.

In ICD-10-PCS, the root operation for this procedure is Transplantation as the objective of the procedure is to take over the function of a body part. The Index main term entry is Transplantation; subterms include Kidney, Right, which direct the user to Table 0TY. The ICD-10-PCS procedure code for this procedure is 0TY00Z0. The fourth character (0) identifies the body part as the right kidney and the fifth character (0) identifies the approach or technique used to reach the operative site as open. The seventh character (0) identifies the donor kidney as allogeneic—taken from different individuals of the same species.

Root Operation M: Reattachment

The definition for the root operation Reattachment provided in the 2014 ICD-10-PCS Reference Manual is, "Putting back in or on all or a portion of a separated body part to its normal location or other suitable location." Reattachment procedures include putting back a body part that has been cut off or avulsed. Nerves and blood vessels may or may not be reconnected during the reattachment procedure. Reattachment procedures can be performed on a variety of body parts, not limited to those that are musculoskeletal. Specific qualifiers are provided for the body parts upper tooth and lower tooth to indicate whether a single tooth, multiple teeth, or all teeth were reattached.

Examples of reattachment procedures include: reattachment of severed left ear; replantation of avulsed scalp; reattachment of traumatic left biceps avulsion, open; and closed replantation of two avulsed teeth, lower jaw.

Comparing ICD-9-CM and ICD-10-PCS: Reattachment

The following is an example of how ICD-9-CM and ICD-10-PCS compare in code assignment for Reattachment procedures.

Scenario: Complex Reattachment

The procedure involves a complex reattachment of an avulsed left middle finger at the medial phalanx level. Small vessels were anastamosed using an operating microscope.

In ICD-9-CM, the Alphabetic Index main term entry is Reattachment; subterm finger. This directs users to code 84.22, Finger Reattachment. ICD-9-CM has a unique code for thumb reattachment.

In ICD-10-PCS, the root operation for this procedure is Reattachment, as the objective of the procedure is to put back a separated body part to its normal location. The Index main term entry is Reattachment; subterms, Finger, Middle, Left. This entry directs users to the Table 0XM. The ICD-10-PCS procedure code for this scenario is 0XMR0ZZ. The fourth character (R) identifies the body part as the left middle finger.

ICD-10-PCS distinguishes the specific finger as well as laterality whereas ICD-9-CM only distinguishes between finger and thumb reattachment procedures without further specificity.

Root Operation X: Transfer

The definition for the root operation Transfer provided in the 2014 ICD-10-PCS Reference Manual is, "Moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part." In transfer procedures the body part remains connected to its vascular and nervous supply. The body system value describes the deepest tissue layer in the flap. The qualifier can be used to describe the other tissue layers when more than one tissue layer is transferred.

Example procedures include: left hand open palmaris longus tendon transfer, open fasciocutaneous flap closure of right thigh, transfer left index finger to left thumb position, and endoscopic trigeminal to facial nerve transfer.

Comparing ICD-9-CM and ICD-10-PCS: Transfer

The following is an example of how ICD-9-CM and ICD-10-PCS compare in code assignment in a Transfer procedure.

Scenario: Local Tissue Advancement Flap

The patient presented for complex closure of an open wound of the left cheek following a dog bite. The closure involved a local tissue advancement flap. The site was cleaned and local tissue flaps were designed for advancement. Undermining was performed and the fascial flap was advanced into the defect. Hemostasis was achieved using electrocautery. Closure was performed under moderate tension with interrupted 5-0 Vicryl. Skin was closed with 6-0 Prolene.

In ICD-9-CM, the Alphabetic Index main term entry is Graft; subterm entry fascia, which directs users to code 83.82, Graft of muscle or fascia.

In ICD-10-PCS, the user may elect to look in the Index under Advancement which provides options to see Reposition or see Transfer. The objective of the procedure is to move the advancement flap into another location without taking out the body part as well as to take over the function of the body part. The Index entry under main term, Transfer; subterms Subcutaneous Tissue and Fascia, Face directs users to Table 0JX. The subterm subcutaneous tissue and fascia was selected as the deepest layer in the flap and is specified as fascia. The complete code for this scenario is 0JX13ZC. The fourth character (1) identifies the body part as subcutaneous tissue and fascia of the face and the qualifier (C) identifies the other tissue layers involved, skin, subcutaneous tissue and fascia. Unlike ICD-9-CM, the ICD-10-PCS procedure code specifies the deepest layer of tissue involved and site of the advancement flap.

Root Operation S: Reposition

The definition for the root operation Reposition provided in the 2014 ICD-10-PCS Reference Manual is, "Moving to its normal location or other suitable location all or a portion of a body part."

Reposition represents procedures for moving a body part to a new location. The range of Reposition procedures includes moving a body part to its normal location, or moving a body part to a new location to enhance its ability to function. In addition, the body part may or may not be cut out or off in order to move it to the new location.

Example procedures include: Relocation of undescended left testicle, percutaneously, open fracture reduction of displaced fracture of right ulna with or without internal fixation, closed reduction with percutaneous internal fixation of right femoral neck fracture, open transposition of ulnar nerve, and laparoscopy with gastropexy for malrotation.

Comparing ICD-9-CM and ICD-10-PCS: Reposition

The following is an example of how ICD-9-CM and ICD-10-PCS compare in code assignment for a Reposition procedure.

Scenario: Closed Reduction with Intramedullary Nailing of Left Femur

Closed reduction of the left femur intertrochanteric reverse obliquity fracture was performed with traction, internal rotation, and abduction of the left lower extremity. C-arm fluoroscopic images confirmed alignment following the reduction maneuver. A 2 centimeter (cm) incision was then made just proximal to the greater trochanter. This was followed by placement of a long 34 cm intramedullary nail over a guide wire. After reaming over the guide pin, a 95-nun hip screw was placed into the subchondral bone. The screw was locked in the proximal aspect of the nail and was confirmed to be in good position on the AP and lateral image.

In ICD-9-CM, the Alphabetic Index main term entry is Reduction; subterms, femur (closed), with internal fixation. This entry directs users to code 79.15, Closed reduction of fracture with internal fixation, femur.

In ICD-10-PCS, it is important to note that the objective of the procedure is to reposition the displaced fracture into its normal anatomic location. The ICD-10-PCS index main term entry, Reposition; subterms femur, upper, left direct users to Table 0QS. The complete code is 0QS736Z. The body part character (7) represents the left upper femur. The approach character is (3) representing percutaneous, as only a minor incision was made to insert the intramedullary nail. The device character (4) indicates the placement of the intramedullary internal fixation device. The ICD-10-PCS code provides information regarding the specific approach, body site—including laterality—and type of internal fixation device used to complete the procedure that is not captured in ICD-9-CM.

References

Centers for Medicare and Medicaid Services. "2014 Code Tables and Index." 2013. http://www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-PCS.html.

Centers for Medicare and Medicaid Services. "2014 ICD-10-PCS Official Guidelines for Coding and Reporting." 2013. http://www.cms.gov/Medicare/Coding/ICD10/Downloads/PCS-2014-guidelines.pdf.

Centers for Medicare and Medicaid Services. "2014 ICD-10-PCS Reference Manual." 2013. http://www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-PCS.html.

Theresa Rihanek (theresa.rihanek@ahima.org) is a director of HIM practice excellence at AHIMA.