Coding Tip: PCS Coding Control vs. More Definitive Root Operation
Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
There were changes made, yet again, to the definition of the root operation “Control”. Per the ICD-10-PCS Official Guidelines for Coding and Reporting 2018, “The root operation Control is defined as, “Stopping, or attempting to stop, postprocedural or other acute bleeding.” If an attempt to stop postprocedural or other acute bleeding is initially unsuccessful, and to stop the bleeding requires performing a more definitive root operation, such as Bypass, Detachment, Excision, Extraction, Reposition, Replacement or Resection, then the more definitive root operation is coded instead of Control.”
The root operation of Control has proven to be confusing to coders since it has changed with each year of coding in ICD-10-PCS. Here are a few examples that will hopefully help coders know when to use or not to use the root operation “Control”.
• Patient presented with GI bleeding and is found to have erosive gastritis during EGD. The area of bleeding is injected with epinephrine to help with control of bleeding and also clips were placed at the site to help with future bleeding. This would be coded using the root operation of Control. There is no other definitive root operation done for this finding, only control of bleeding.
• Patient presents with GI bleeding and is found during EGD to have bleeding esophageal varices. The patient has banding of the esophageal varices. This would be coded using the root operation of Occlusion. This is a more definitive root operation than just control of bleeding.
• Patient presents with epistaxis for the past several hours. In the ED, the patient receives nasal packing using tampon to help with the bleeding. This would be coded using the root operation of Packing.
• Patient presents with internal injury due to MVA with internal bleeding noted in the ED. The patient is found to have severely lacerated kidney during exploratory laparotomy. During the surgery it is determined that the patient’s kidney is unsalvageable and decision to remove the kidney was made. The removal of the entire left kidney was performed. This would be coded using the root operation of Resection. Even though removing the kidney stopped the kidney bleeding/hemorrhage, the appropriate root operation is Resection and not Control. Resection is a more definitive root operation so that is what should be used.
• Patient presented with acute bleeding of an artery status post abdominal hysterectomy. The physician dissects down and then ligates the bleeding artery with a suture and closes the area. This would be coded using the root operation Control as there is not a more specific root operation other than repair.
ICD-10-PCS Official Guidelines for Coding and Reporting 2018, Page: 6
AHA Coding Clinic, Fourth Quarter 2017 Page: 105-106
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
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