Q&A: Educating providers on root operations

Q: I’ve heard that provider education should not include lectures on the definitions associated with the root operations. What should be covered in provider education instead?

A: Per ICD-10-PCS 2019 Official Guidelines for Coding and Reporting, under “Conventions,” p. 3, section A11, it states:

Many of the terms used to construct PCS codes are defined within the system. It is the coder’s responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear.

Example: When the physician documents “partial resection” the coder can independently correlate “partial resection” to the root operation Excision without querying the physician for clarification.”

Based on this information, we know that physicians do not have to use the same terminology used in the definitions of the 31 root operations used in ICD-10-PCS for a procedure to be coded appropriately. What the coder does need, however, is accurate information in the post-operative note so that they can assign the appropriate root operation along with the most appropriate six other characters necessary for a valid code.

Although it is not the responsibility of the physician to assign the root operation, we want to make sure that their documentation is clear, concise, and accurate. This ensures that when the coders are reviewing the record, they have all the necessary information to assign a code for the intervention or procedure.

So, as a clinical documentation specialist, your job would include educating the providers that all of their documentation is important, making sure all necessary details are included in their notes. Whenever a CDI specialist feels there’s clarification needed, we should query.

I would also recommend reviewing the ICD-10-PCS 2019 Official Guidelines for Coding and Reporting which can be found here.

Editor’s Note: Sharme Brodie, RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps, click here.