Coding Tip: Getting Control of Root Operation Control

by Aug 7, 2018Industry News, Medical Coding Tips, Patricia Maccariella-Hafey0 comments

Patricia Maccariella-Hafey, RHIA, CDIP, CCS, CCS-P, CIRCC has over 35 years expertise in the areas of ICD-9-CM, CPT, DRG/APC validation Professional Fee E&M coding, Interventional Radiology, and Facility E&M coding. Patricia is currently Director of Education a healthcare consulting firm specializing in coding compliance review, education and contract coding services.

Pat Maccariella‑Hafey

Executive Director Of Education
AHIMA‑Approved ICD‑10‑CM/PCS Trainer and Ambassador

As seen in AHIMA’s August 2018 edition of CodeWrite

Since the implementation of ICD-10-PCS in 2015, yearly changes have been made regarding the definition of, and guidelines associated with, the root operation Control. This has caused coding professionals much confusion in determining whether to assign a procedure to root operation Control, to assign another root operation, or to not assign a procedure code at all. The objective of this article is to learn when the root operation Control should be assigned when coding a procedure.

Clinical Information
Control of bleeding is necessary during surgery as an integral part of the overall procedure. It is many times referred to as “hemostasis” in the operative report. The routine process of hemostasis during surgery is not separately coded. It is when this bleeding is postoperative and goes beyond the normal expectations that the bleeding becomes an issue and reporting a code for control of bleeding becomes necessary.

Acute bleeding occurs in many different diagnoses, including gastrointestinal ulcers, epistaxis, arteriovenous malformations, and traumatic injuries. When this bleeding is problematic, control is necessary to alleviate risk to the patient. There are various ways a physician can control postoperative or other acute bleeding. In addition, a patient may have intermittent bouts of bleeding. The patient may be scheduled for a procedure to control the bleeding. The fact that the patient may not be bleeding at the time of the procedure does not preclude reporting a procedure code for control of the bleeding.

Click here to read more about the coding conventions, guidelines involved, and to learn more about the progression of the definition change for root operation Control.



The information contained in this post 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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